American International School of Kingston: Medical Form

STUDENT INFORMATION: PERSONAL (To be completed by Parent)

Last

First

Middle

Preferred Name (s)

MEDICAL EVALUATION: IMMUNIZATION RECORDS (To be completed by Parent)

Immunization Records must be up to date: DPT, HIB, Polio , MMR and Hep B. Please attach here.

Attach File

Max file size: 10 MB

Asthma

If YES please provide details

Yes No

Anaphylaxis
If YES, please provide details

Yes No

Allergies
If YES, please provide details

Yes No

Diabetes
If YES, please provide details

Yes No

Seizures
If YES, please provide details

Yes No

PERMISSIONS TO ADMINISTER MEDICATION

With your permission, the school nurse can administer the following without contacting you first. Should your child complain of minor pain or other problem while at school, the School Nurse will administer over-the-counter medications such as:

Radio Buttons

Yes No

Tylenol/Panadol, Ibuprofen (non-aspirin)

Radio Buttons

Yes No

Antacid tablets (for stomach)

Radio Buttons

Yes No

Cough or sore throat lozenges/syrup

Radio Buttons

Yes No

Benadryl (for allergies)

Radio Buttons

Yes No

Topical ointment for rashes, etc.

Radio Buttons

Yes No

I give permission to the school nurse to administer as listed above by electronic signature below.

Electronic Signature

PARENT AGREEMENT AND CONSENT

1. in the event that my child becomes ill and needs to go home, it is my responsibility to arrange transportation for my child to be picked up at school.

2. I understand that my child will undergo health screenings by the school nurse.

3. I understand that in the event of a medical emergency, every effort will be made to notify parents/guardians as soon as possible.

4. I further consent to emergency procedures to be initiated in case of injury/accident or illness treatment of any sort deemed necessary, and I shall not hold him/her liable in a court of law.

Electronic Signature

Date

ADDITIONAL INFORMATION: EMERGENCY CONTACT INFORMATION Parent will be called first

Emergency Contact Name

Relationship to Student

Home #

Work #

Mobile #

Emergency Contact Name

Relationship to Student

Home #

Work #

Mobile #

Physician

Student's Physician 1

Office Address

Office Phone #

Mobile #

Student Physician 2

Office Address

Office Phone #

Mobile #

Dentist

Student's Dentist

Office Address

Office Phone#

Mobile #

Orthodontist

Student's Orthodontist

Office Address

Office Phone#

Mobile #

Your electronic signature in the appropriate space below indicates that you agree to the terms of this application.

Mother's Signature

Father's Signature

Date (mm/dd/yyyy)

Please send a confirmation email to the address below*:

Please provide an email address where we can send a link to your current form.

Email Address :