Christa McAuliffe Regional Charter Public School

Medical Information/Permission to Treat for Overnight Fieldwork

EMERGENCY CONTACT INFORMATION

Student Name:__________________________________________Date of Birth:________________________

Address:__________________________________________________________________________________

Home Telephone:_________________________________________________________

Custodial Parent #1:_____________________________________Daytime Telephone:____________________

Custodial Parent #2:_____________________________________Daytime Telephone:____________________

Primary Care Physician Name:________________________________________________Telephone:___________________________

Insurance Company and Policy Number:_________________________________________________________

Emergency Contact Information (if parent not available)

Name:_________________________________________________Relationship:_________________________

Home Telephone:______________________________Work Telephone:_______________________________

Cell Phone:___________________________________

MEDICAL INFORMATION

1. Does your child have any allergies? If yes, what is he/she allergic to and what does the reaction look like?________________________________________________________________________________________

___________________________________________________________________________________________

2. Has your child been exposed to any communicable diseases in the past 21 days? If yes, what disease____________________________________________________________________________________

__________________________________________________________________________________________

3. Is there any factor which makes it advisable for your child to follow a limited program of physical activity, i.e. heart condition, asthma, recent fractures, injuries, or surgery, abnormal fears?_____________________________________________________________________________________

4. Immunizations (tetanus-diptheria, polio, hepatitis B) up-to-date?____________________________________

5. Will your child require any medication/vitamins/herbal supplements while on the fieldwork?

__________________________________________________________________________________________

6. Does the medication require refrigeration?______________________________________________________

8. List each medication with complete directions  (time, dosage, frequency) and reason for taking: ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

SOCIAL EMOTIONAL INFORMATION

Does your child sleepwalk or talk?.....................................................Yes                     No

Does your child have frequent nightmares or night terrors?.................Yes                      No

Is your child afraid of the dark?.........................................................Yes                      No

Does your child wet the bed?............................................................Yes                      No

Is your child anxious about being away from home?..........................Yes                       No

Has your daughter started menstruating?...........................................Yes                       No

Is there anything else we should know about your child which may impact his/her experience on this overnight fieldwork?________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

CONSENT TO ADMINISTER MEDICATION AND PERMISSION TO TREAT

If your child will be taking medication while on fieldwork, please note the following requirements;

• A physician’s order is required for each medication, even if it’s an over the counter medication, herbal preparation, or vitamin. All written orders must be received by the nurse one week prior to the fieldwork date.

• All medications must be delivered directly to the nurse or authorized fieldwork staff member by a responsible adult one day prior to the trip date.

• At no time is the student allowed to carry or administer his/her own medication, including over the counter medications, herbal preparations, or vitamins. The only exception to this is students who have prior authorization to self-administer epi-pens and/or inhalers.

• All medication must be in its original container, clearly labeled with the student’s name.

I _________________________________________________ give my permission for medication to be

(Parent/Guardian name)

administered to _____________________________________________________________________.

                                                       (Student name)

I understand medication will only be administered by the nurse or CMRCPS Staff who have been specially trained to administer medication.

In case of illness or injury involving my child, I understand every effort will be made by school authorities to notify the parent listed on this form. In the event of an emergency that requires immediate medical attention, I understand my child will be transferred by ambulance or other emergency vehicle to a hospital and be treated by a physician.

_________________________________________________________________Date_____________________

(Signature Parent/Guardian)