Livingston Public Schools
11 Foxcroft Drive
Livingston, NJ 07039
973-535-8000
www.livingston.org
Confidential Medical Information Form*
(Form to be completed by parent/guardian.)
____2015-2016___________ School Year
Student ID:
Student’s Name:
Grade:
Physician’s Name:
Teacher:
Office Phone Number:
Does your child take any medication regularly? If yes, complete below.
Medication:
Dosage:
Time Administered:
Dosage:
Time Administered:
Dosage:
Time Administered:
Purpose of Medication:
Medication:
Purpose of Medication:
Medication:
Purpose of Medication:
The school nurse has my permission to administer the following medications to my child during
the school day:
Tylenol/Acetaminophen
Tums
Advil/Motrin/Ibuprophen
Cough Drops
Does/Did your child have any of the following? If YES, please give details below.
Allergies (pollen, food, hives, medicine): List allergens and types of reactions below:
(If an EpiPen injection is necessary, a “permission to dispense” form must be submitted
every school year.)
Yes
No
Asthma (allergic, exercise induced) – describe symptoms and treatment below:
(If an inhaler is necessary, a “permission to dispense” form must be submitted every school
year.)
Bee Stings (If YES, you MUST provide medication.)
Hearing Difficulties
Eyeglasses/Contact Lenses – when should they be worn?
Fainting with Exercise
Any previous joint disease, injuries, fractures?
Loss of consciousness after injury?
Diabetes
Heart problems, chest pain, palpitations, murmur?
Surgery(ies) – list dates and reason below:
(Page 1 or 2)
Revised 6/2015
CONFIDENTIAL MEDICAL INFORMATION FORM
Has your child ever been hospitalized? If YES, please give details below.
Hospitalization(s) – list date and reason below:
Yes
No
Do you have any concerns about your child’s health that would impact on his/her role as a
student?
If your child has a history of allergies, takes medication, wears eyeglasses/contacts or has any health related
concerns, it is important to give that information to the school nurse. The Family Education Rights and Privacy Act
(FERPA) has issued regulations which require public schools to obtain written consent to disclose medical information.
All information will be held in the confidence by the school nurses and will be shared only with other school
professionals as necessary. If you have any concerns or question please do not hesitate to contact the school health
office.
I give my permission for release of information on this form for confidential use in meeting my child’s health and
educational needs in school.
Signature of Parent/Guardian
Date
NOTE: Height and weight yearly screening information will be transmitted by the school nurse for students in grades
4 through 12 to their Physical Education teacher. This data may be used in conjunction with the PE Fitness
Assessment Program (Fitnessgram) to provide students and parents with information about their overall health and
fitness level as part of the educational program. Check here ____ if you do not agree with sharing your child's
height and weight for their physical education program.
Does your child have health insurance including NJ FamilyCare/Medicaid, Medicare, private or other?
YES, my child has health insurance.
NO, my child does not have health insurance; you may release my name and address to the NJ
FamilyCare Program to contact me about health insurance.
I give my permission for release on this form for confidential use in meeting my child’s health and
educational needs in school.
Print Name of Parent/Guardian
Signature of Parent/Guardian
Date
*Athletes (including intramurals) in grades 6-12 must also complete the Annual Athletic Pre-Participation
Physical Examination Form which is required by the State of New Jersey prior to participation as per
N.J.A.C. 6A:16 Programs to Support Student Development. This form can be found on our district, middle
and high school websites.
Revised 6/2015
CONFIDENTIAL MEDICAL INFORMATION FORM