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Student’s Name (please
print)_____________________________________________
Telephone Number_____________________________________________________
A health care provider will administer first aid, life support
in the form of CPR, and/or
call emergency personnel and transportation as deemed
necessary. The heath provider
will be on site mornings, noontime and in the evening and will
be on call by phone on a
twenty-four hour basis to instruct the residential staff on
how to deal with student
illness/injury. Health advice and education will be given as
needed for illness and injury prevention. A record of
students treated will be maintained to enable the health care
provider
to monitor health conditions and reduce the risk of
disease transmission.
For the safety of all students, we do not
allow any medications to be kept in the student’s
rooms
unless deemed safe and appropriate by the health care
provider. We keep the
following medications on hand. Please indicate if we have
your permission to administer
these medications at the discretion of the health care
provider or designee.
Yes No
___ ___ Antihistamine (Benadryl)
___ ___ Acetaminophen (Tylenol)
___ ___ Ibuprofen (Advil)
___ ___ Cough Drops
___ ___ Sore Throat Spray
___ ___ Clariten (parent must
provide)
___ ___ Other (please list any over-
the-counter medicines you think your child may
use at PCC). Parent must
provide:_________________________________________
The completion of this form requires
the SIGNATURES of both PARENT and PHYSICIAN and must
be returned no later than May 30, 2007.
I________________________Date_________(parent/guardian
signature and date) authorize the PCC health provider or
designee to administer the above medications,
marked in the affirmative, as he/she deems appropriate to my
child while in attendance at
PCC. I have read the above health and medication policies.
Understand and agree to
adhere to them.
I________________________Date_________(physician’s
signature and date) believe this student is healthy and
able to participate in the PCC Program with no limitations
unless otherwise noted on this form. I authorize that the
above medications marked in the
affirmative may be
administered as deemed appropriate by the staff nurse. (Note:
A well-
child physical or camp form is not necessary)
*Note: If you checked YES on the
Parental Questionnaire that the student will require
prescription medication during the Program, the office will
mail a Prescription
Administration Form that must also be completed by you and
a licensed prescriber and submitted to the PCC Office. Both
the Student Health Form and the Prescription
Administration Form are due no later than May 30, 2007.
This form is to be completed and
submitted for students that require prescription
medication while at PCC. Both parent and
licensed prescriber’s sections must be
completed and submitted no later than May 30, 2007.
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