Prentice Summer Program
Medical
The Required medical forms include:
1.
Medical Treatment Consent Form
REQUIRED FOR ALL STUDENTS
2.
Emergency/Medical Information Form
REQUIRED FOR ALL STUDENTS
Parent/Guardian & licensed authorized
health care provider/dentist Request for
Medication
REQUIRED for ANY student who takes PRESCRIPTION
MEDICATION that needs to be administered by school staff for
ANY REASON including:
1. During school hours
2. On an “as-needed” or emergency basis (including inhalers
& EpiPens)
3.
Please complete the forms and return to The Prentice School within 3 days of enrolling via
fax (714-538-5004), email sisadmin@prentice.org, mail, or drop-off at front desk.
Prescription Medications:
Medical treatment is the responsibility of the parent/guardian and an authorized health care provider. An authorized
health care provider is an individual who is licensed by the State of California to prescribe medication. Both
prescription and over the counter medication may be given at school when it is deemed absolutely necessary by
the authorized health care provider that the medications be given during school hours. California Education Code, Section
49423 allows school personnel to assist in carrying out an authorized health care provider’s written orders. The
parent/guardian is urged, with the help of your child’s authorized health care provider, to work out a
schedule of giving medication at home whenever possible.
Emergency medicine such as EpiPens or inhalers may be carried by the student
(GRADES 5 – 8 ONLY) when recommended by an authorized health care provider and parent. Back-up
medication should be kept at school for emergency use. Students who have a serious medical condition (diabetes,
epilepsy, etc.) should have an emergency supply of their prescription medication at school with the appropriate consent
forms in the event of a disaster.
If medication is to be administered at school, all of the following conditions must be met:
1. Parent/guardian and an authorized health care provider must complete and sign the required form
and return to the Prentice School.
2. Medication must be delivered to the school by the parent/guardian or other responsible adult.
3. Medication must be in your child’s original, labeled pharmacy container written in English.
4. All liquid medication must be accompanied by an appropriate measuring device.
5. Any tablets requiring partial doses (½ or ¼) must be sent to school already cut.
6. A separate form is required for each medication.
Whenever there is a change in medication, dose, time, or route, the parent/guardian and authorized health
care provider must complete a new form.
MEDICAL TREATMENT CONSENT FORM
Summer 2015
This is a mandatory form that must be completed for each student
Student First Name:
Student Last Name:
Name of Medical Insurance Provider:
□ I AUTHORIZE
□ I DO NOT AUTHORIZE
DOB:
Grade:
Policy/Contract/Group #:
The Health Clerk or other designated staff to give my child the common medications (or
generics) listed below, if needed, at school.
----- I HAVE CROSSED OUT THE MEDICATIONS THAT I DO NOT WISH MY CHILD TO RECEIVE. ----ANALGESICS
INDIGESTION/DIARRHEA
TOPICALS
EYE
Ibuprofen*
Antacid/anti gas*
Antibiotic Ointment
Eyewash
Acetaminophen*
Antidiarrheal*
Antiseptic Towelettes
Eyedrops/Artificial Tears
First Aid Antiseptic Pain Reliever
Contact Lens Solution**
**Students with contacts should bring both
COLD/ALLERGY
MOUTH
Hydrocortisone Cream
Antihistamine*
Oral Pain Reliever
Hydrogen Peroxide
re-wetting and cleaning solutions along with
Throat Lozenges
Petroleum Jelly/Carmex
an extra case and/or extra pair of lens (if disposable)
Dental Wax
Sting/Bite Relief
*Available in liquid, tablet, or chewable forms (depending on stock)
If you do not give consent, please provide instructions:
□ YES
□ NO
my child requires prescription medication (including rescue inhaler or EpiPen) that needs to be taken
during school hours AND/OR on an emergency or “as-needed” basis.
If you answered “YES”, you MUST complete an ADDITIONAL form, “Parent/Guardian & Physician Request for Medication”, which
requires BOTH a parent/guardian AND a licensed authorized health care provider/dentist to fill out and sign.
NO PRESCRIPTION MEDICATIONS WILL BE GIVEN WITHOUT THIS FORM
RELEASE OF LIABILITY, AGREEMENT TO HOLD HARMLESS, AND COVENANT NOT TO SUE: To the full extent permitted by law, I/we knowingly and voluntarily
release and covenant not to sue The Prentice School, its trustees, officers, directors, employees, agents, representatives, coaches, volunteers (the Released Parties) from any
and all claims and liabilities that arise out of, or relate to The Prentice School’s administration of medications (prescription or non-prescription) to my child consistent with the
terms of this form, or my child’s self-administration of medications while on campus or at a School-related event, or the rendition of any medical treatment to my child that
has been authorized by The Prentice School acting pursuant to this form. I understand however, that through this Agreement I am not releasing the Release Parties from
any injury my child suffers as a direct result of the Released Parties’ intentional misconduct or gross negligence. I further agree to hold The Prentice School harmless and to
defend The Prentice School for all costs, expenses, judgments or any other liability to any other person who shall assert any claim on behalf of themselves or my child that
arises out of, or relates to, the Prentice School’s administration of medications to my child consistent with the terms of this form, or my child’s self-administration of
medication while on campus or at a School-related event, or the rendition of any medical treatment to my child that has been authorized by The Prentice School acting
pursuant to this form. By my signature below, I acknowledge that I have fully read and understand that I am releasing and covenanting not to sue The Prentice School on
behalf of my child, myself or any other person and holding it harmless, according to the terms of this paragraph.
CONSENT FOR MEDICAL TREATMENT & RELEASE FROM LIABILITY: In the event my child becomes ill or injured and, in the sole and unfettered discretion of any one
of the Released Parties, requires immediate medical or dental care or attention at any School or School-related practice, game, program, trip, or similar event (on or off
campus) or while otherwise on school premises, I authorize the School and their agents or employees to consent on my behalf to x-rays, examinations, anesthetic, medical or
surgical procedure, treatment or hospital care, which are deemed advisable by and to be rendered under the supervision of any physician, surgeon, or dental surgeon
licensed under the provisions of California state law, whether such diagnosis or treatment is rendered at the scene of the event, the office of a physician or dentist, or at any
hospital. I understand and agree that this consent to treatment in advance following the provisions of California Family Code §6910 does not relieve the parent or guardian
for all financial responsibilities for such treatment. I understand that The Prentice School will make a reasonable effort to contact me to assist in any decision made by the
school, but that the School will be compelled to use its best judgment should it not be possible to contact me. It is understood that this authorization is given in advance of
any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to
any and all such diagnosis, treatment or hospital care which the aforementioned physician or dentist in the exercise of his best judgment may deem advisable.
ASSUMPTION OF RISK: I assume all risks arising out of, or relating to The Prentice School or any of the Released Parties providing prescription and/or non-prescription
medication to my child consistent with the terms of this form/physician’s instructions. I have fully investigated the procedures by which The Prentice School and each of the
Released Parties administers and supervises self-administration by students of medication, and I expressly agree that I am satisfied with them with regard to my child. I
acknowledge that the risks to my child include, but are not limited to, failure of any such medication (so long as it has been authorized for sale and/or distribution in California
by state or federal authorities) to be safe and/or effective, mild or severe adverse physical reaction to the prescription and/or non-prescription medication provided (including
emotional/psychological harm), permanent and temporary disability, and death. I agree that my child will also assume these risks and any other risks arising out of, or
relating to, The Prentice School or any of the Released Parties providing prescription and/or non-prescription medication to my child consistent with the terms of this form.
USE OF HEALTH RECORD: All of the information I provided during online registration relating to the medical history and information regarding my child is complete, true,
and correct. I hereby give permission for this information to become part of the student’s educational record and give permission to The Prentice School to share the
student’s medical information with school personnel who have legitimate educational interests in this information and to provide any such information to any medical
personnel in connection with any medical treatment provided to my child.
I HAVE CAREFULLY REVIEWED THIS FORM AND FULLY UNDERSTAND ITS CONTENTS (INCLUDING THAT THIS FORM CONTAINS CERTAIN RELEASES OF
LIABILITY AND OTHER PROVISIONS AFFECTING MY CHILD’S AND MY LEGAL RIGHTS AND DUTIES), AND AGREE THERETO. THIS AUTHORIZATION SHALL
REMAIN EFFECTIVE FOR THE FULL SCHOOL YEAR UNLESS REVOKED IN WRITING AND DELIVERED TO THE PRENTICE SCHOOL AND A RECEIPT FOR THE
REVOCATION IS ISSUED.
PARENT/GUARDIAN SIGNATURE
DATE
PARENT/GUARDIAN PRINTED NAME
EMERGENCY/MEDICAL INFORMATION FORM
Summer 2015
This is a mandatory form that must be completed for each student for each new school year.
Complete All Sections
Please PRINT
STUDENT INFORMATION
First Name:
Last Name:
Grade (SY 2015-16):
Street Address:
DOB:
City:
State:
Zip:
Home Phone:
MOTHER/GUARDIAN INFORMATION
FATHER/GUARDIAN INFORMATION:
Name:
Name:
Cell:
Cell:
Employer:
Employer:
Home Address, City, State, Zip:
Home Address, City, State, Zip:
(If different from above)
(If different from above)
Work Phone:
Work Phone:
Email:
Email:
MEDICAL INFORMATION
Please provide a brief medical history for Prentice to keep on file in the event of emergency medical treatment by medical professionals.
Does student have any unusual health conditions? (If YES, please check below) ___Yes ___No
Student's Blood Type:
__ Asthma
__ Kidney/Bladder
__ Arthritis
__ Wears Glasses/Contacts
__ Headache/Migraine
__ Convulsive Seizures
__ Internal Irregularities
__ Diabetes - Mild
__ Diabetes - Severe
__ Wears Hearing Aid
__ Physical Handicap (Describe)
Does student have any allergies?
__ Other (Describe)
__ Yes
__ No
__
__ Medication Allergy
Bee Sting Allergy
___ Peanut Allergy
__ Other: (Describe)
STUDENT RELEASE INFORMATION
I authorize the following people to pick up my child from school:
Please list in order of priority
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
I HEREBY AUTHORIZE PRENTICE STAFF TO RELEASE MY STUDENT TO THE ABOVE LISTED PERSON(S)
PARENT/GUARDIAN SIGNATURE:
NOTE: If there is any legal reason for which an individual is Not allowed to pick up or interact with your child, please write the names(s)
below and provide The Prentice School with a copy of legal documentation so that we may place it in your child's file
Name:
Relationship:
PARENT/GUARDIAN & LICENSED AUTHORIZED HEALTH CARE
PROVIDER/DENTIST REQUEST FOR MEDICATION
Summer 2015
THIS REQUEST IS VALID FOR THE CURRENT SCHOOL YEAR. A SEPARATE FORM IS REQUIRED FOR EACH MEDICATION
Student First Name:
Student Last Name:
DOB:
Grade:
PARENT/GUARDIAN REQUEST FOR THE ADMINISTRATION OF PRESCRIPTION MEDICATION
California Education Code Section 49423 provides that pupils who are required to take prescribed medications during the school day can be and will
be assisted by the Health Clerk and/or other designated School Personnel ONLY if the school receives the written request from said licensed
authorized health care provider/dentist and the parent/guardian(s) of named student. Medication must be in the student’s original, labeled pharmacy
container.
I request that medication be administered to my child in accordance with our licensed authorized health care provider/dentist written instructions. I
understand that designated school personnel will administer the medication. I will notify the school immediately and submit a new form if there are
changes in medication, dosage, time of administration.
PARENT/GUARDIAN SIGNATURE:
DATE:
Emergency medicine such as an EpiPen or inhaler may be carried by 5-8 grade students ONLY when recommended and signed by a
licensed authorized health care provider/dentist and parent. Back up medication should be kept at school for emergency use.
**** Prescribing physician must complete this section. ****
Reason for medication (diagnosis):
Medication:
Dose:
If PRN: Amount of time between doses:
Route:
Time:
Maximum number of doses per school day:
Possible medication reactions:
Instructions for emergency care:
Date of request:
Date to discontinue medication:
The above medication can’t be scheduled for other than school hours and may be
administered by school personnel.
Physician’s Printed Name:
Date:
Address:
Phone:
Fax:
PHYSICIAN’S SIGNATURE:
*****GRADES 5 – 8 ONLY*****
Regarding EpiPens/Inhalers: It is my professional opinion that this student should be
permitted to carry/self-administer this emergency EpiPen or inhaler. This student has been
instructed in, and demonstrates an understanding of proper usage.
Office Stamp
Health Care Provider Initials:
OFFICE USE ONLY:
Health Office Staff:
Date Form Received:
Medication Name Received:
Amount:
Date Meds Received: