Lee’s Summit R-7 School District Medication Record 2015-2016 Student:______________________________________________DOB:___________________ Teacher/Gr/Rm:_____________________________ Year:______________ School:____________________ Date:____________ Medication:______________________________________ Label Instructions/Time:_______________________________________________________________________________ RN approval/date:_________________________________________________________________ Verbal Order approval/date:_____________________________________________________________ Dose change Date:______________ Medication:______________________________________ Label Instructions/Time:_________________________________________________________________ RN approval/date:_________________________________________________________________ Verbal Order approval/date:_____________________________________________________________ Special Instructions: _____refrigerate _____spacer _____other:_______________________________________________________________________________________________________________ 1
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August
X
September October
X
November December January
X X X
February March
X
April May
X
June July CODES: (A)Absent (D)Early Dismissal (DC)Discontinue (DW)Dose Withheld (F)Field Trip (0)No Show (N)None Available (S)Snow Day Weekend/Holiday/No School Signature of Person Administering Medication
Initials
Date
Date:_______________ Medication returned / destroyed
LEE’S SUMMIT R-7 SCHOOL DISTRICT MEDICATION CONSENT FORM
Name:_______________________________________ Date of Birth:_____________________ Age:__________ School: ____________________Grade /Teacher: ______________________
Known Drug Allergies (list) ________________________________________________________________________
*Medication must be in the original container and brought to the Health Room and picked
up by a parent/guardian* Name of Medication to be given at school: _______________________________________________________ Reason for Medication: ______________________________________________________________________ Dosage: _______________________________________________________ Time(s): ___________________ Dosage: _______________________________________________________ Time(s): ___________________ Physician’s Name:_________________________________________ Phone Number:_________________________ Physician’s Signature:___________________________________ Date:_______________________________ (Prescription label will suffice as physician signature) Do you want the mid-day dose given on early release day?
Yes No
I hereby give permission for my student to receive the above medication at school.
I have given the first dose of medication at home.
I hereby give permission for the school nurse to communicate with the prescribing physician.
I understand that all unused, discontinued and/or expired medication not picked up by a parent/legal guardian at the end of the school year will be destroyed.
NOTICE Schools in this district are equipped with pre-filled epinephrine auto-syringes that can be administered in the event of severe allergic reactions that cause anaphylaxis. Epinephrine will be administered in accordance with written protocols provided by the authorized prescriber, except for students authorized to carry and self-administer epinephrine in accordance with LSR7 Board Policy.
There are some medications that the district does not delegate administration of to unlicensed personnel. For more information, see Board Policy JHCD: Administration of Medication to Students and Administrative Procedure JHCD -AP: Administration of Medication to Students at www.lsr7.org Rev 2014
Medication Record with parent permission form on back.pdf ...
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Health Insurance Company Policy Number. Page 1 of 1. Parent-Permission-Form-Fillable.pdf. Parent-Permission-Form-Fillable.pdf. Open. Extract. Open with.
Page 1 of 5. DHE,C. ffiffiffi. Catherine E. Heiel, Director ?irt;tic1t;;y rtttr/ fttt;i1;;ji7g tl,t /'rrtlr/; $thr: publit',ti*1 tly r;.;t i;z;y::t:;ti. January 2016. Dear Parents/Guardians : The Tdap vaccine protects children from three serious dise
Page 1 of 2. HANDBOOK AGREEMENT/PERMISSIOM. PLEASE FILL OUT, SIGN, AND RETURN. (Signatures required on both sides of this form!) JHCA-E-2. HANDBOOK AGREEMENT. I,. , understand and agree to abide by the rules in the Athletic. (Student-Athlete Name). H
Page 1 of 1. Page 1 of 1. Parent Permission Slip.pdf. Parent Permission Slip.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying Parent Permission Slip.pdf. Page 1 of 1.
Page 1 of 1. NEW YORK STATE PUBLIC HIGH SCHOOL ATHLETIC ASSOCIATION. WRESTLING MINIMUM WEIGHT ASSESSMENT. PARENTAL AWARENESS FORM. The appropriate and healthful control of body weight for wrestlers has been a concern of athletes, coaches,. athletic t
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The District shall make no distinction between absences for UIL activities and absences for other extracurricular activities approved by the Board. A student shall be allowed in a school year a maximum of ten extracurricular absences not related to p
______ List of family members or friends that might pick her up: Please list any medical condition we should be aware of such as asthma, allergies ... ADDRESS: ...
Chaperones are asked to pay the $40 fee. _____ I cannot chaperone but would like to stay for a meal. _____ Friday supper $8.50. _____ Saturday lunch $7.00. _____ My child needs a ride with another member. Salem Youth Symphony. 503-485-2244. PO Box 11
the general or specific supervision and on the advice of any physician, dentist, or surgeon; licensed to practice in. the State of Arizona or any other state. The undersigned understand(s) and agrees that any medical, dental, or. hospital expense inc
Page 1 of 2. ESUMS HIGH SCHOOL. 130B LEEDER HILL 06517. PHONE: 203-946-5882. GUEST PERMISSION FORM FOR ATTENDING. SCHOOL DANCE. COMPLETE BOTH SIDES AND RETURN FORM TO SECRETARY-TERESA FLOWERS. Name of ESUMS High School Student (please print): ...
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Have my healthcare provider complete a new medicine form for my child if the medicine or dose changes. I agree for child's healthcare provider to talk with the ...
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Page 1 of 2. Member Information â Please use black or blue ink and CAPITAL LETTERS only. Last Name First Name MI Suffix. Member ID Plan Name. Date of Birth Gender Number of New. Prescriptions. Group Number. Mobile Phone (Include area code)* Set as