Medication & Health Record Medications required during school: (name, strength, amount, regular or as needed, how often, and specific instructions).
Additional specific instructions for medication.
Is your child on allegy injections?
Does you child use an inhaler?
Does you child have Asthma?
Does you child have a specific Asthma Action Plan?
Who is responsible for giving you child's asthma medication at home?
On a scale of 0-10, how bad (severe) has your child's asthma been over the last year? (10 Being Severe/Choose One Only).
Describe any emotional effects you have observed in your child due to asthma.
Is your child allergic to any MEDICATION (penicillin, sulfa, etc.)?
If yes, please list. (Medication Name, Reactions-specific symptoms, severity, when they start, etc.,age of last reaction).
Is your child allergic to any FOODS?
If yes, please list. (Food Name, Reactions-specific symptoms, severity, when they start, etc.,age of last reaction).
Is your child allergic to any ANIMALS?
If yes, please list. (Animal Name, Reactions-specific symptoms, severity, when they start, etc.,age of last reaction).
Is your child allergic to any INSECTS?
If yes, please list. (Insect Name, Reactions-specific symptoms, severity, when they start, etc.,age of last reaction).
Was emergency treatment needed for any of the reactions listed above (ex. 911, ER Visit, Urgent Care, EpiPen)?
If yes, please explain.
Specifically, does you child have any of the following? Attention Deficit Disorder?
Obsessive Compulsive Disorder?
Date of most recent tetanus booster. DPT, Polio, and MMR immunizations up-to-date?
Are there any other medical problems or conditions your child ha that the school should know about?
If yes, please explain.
Has your child ever been away from home and parents?
If yes, were there any problems?
Do you anticipate any problems with homesickness?
Does your child feel embarassed at school or in public if they have to take an inhaler?
Do you anticipate any activity restrictions?
If yes, please explain.
Are there any present physical education restrictions at school?
If yes, please explain.
Is there any else you feel school staff should know about your child?
If yes, please explain.
PARENT'S AUTHORIZATION
PARTICIPATION AND EMERGENCY TREATMENT WAIVER In consideration for being allowed to register and participate in school, held in the school year entered below, sponsored by Echelon Academy, as parent/guardian I hereby release the Association, its Incorporators, Physicians, Board Members, Officers, Employees, Agents, Independent Contractors and Volunteer Workers from any liability for injuries which are sustained during the school, including any necessary transportation. The child herein described has permission to engage in all scheduled activities except as noted by the physician or parent/guardian. I hereby give permission to the school to initiate and provide any necessary treatments, including transporting to the nearest certified emergency facility. If hospitalization is required, the child is to be referred to an appropriate physician and all treatments will be at my expense. Submit
