Palmer public schools

PALMER PUBLIC SCHOOLS
PALMER HIGH SCHOOL----HEALTH SERVICES
Student Health Information Sheet (School Year ___________)

Name _______________________ M/F GR____ DOB__________ Birthplace ____________________
Street Address___________________________________
Home phone _________________________
Mailing Address__________________________________ Cell phone ___________________________
Town/Village_____________________________________
Lives with:

Mother/Guardian__________________________
Daytime location __________________________ Daytime phone ___________________________ Father/Guardian__________________________
Daytime location __________________________ Daytime phone ___________________________ Stepparent ______________________________
Daytime location __________________________ Daytime phone ___________________________
List brothers and sisters & their ages ________________________________________________________
Emergency contacts (In case a parent cannot be reached, list 2 adults available during school hours to
transport your child home or to a hospital or physician’s office.) Daytime location __________________________ relation _________________________________ Daytime phone ___________________________ Daytime location __________________________ relation _________________________________ Daytime phone ___________________________ Health insurance name (if no coverage, write NONE) _____________________________________
In case of serious illness or injury, I request school personnel to contact me. If I cannot be reached, I give permission for the school
nurse to cal my child’s physician or the school physician and follow his/her direction. In an emergency, school personnel may make
any arrangements for medical care that seem necessary including transport to a hospital by ambulance. If my child needs to be
dismissed for any reason, I will be responsible to find an appropriate adult to accompany the child home or for medical attention.
Parent/Guardian signature ___________________________________________ Date _________________
___________________________________________________________________________________________________
PLEASE SIGN BELOW FOR YOUR CHILD TO RECEIVE OVER-THE-COUNTER (OTC) MEDICATIONS AT SCHOOL.

I give permission for the School Nurse to administer, at his/her discretion, the following:
FOR PAIN/DISCOMFORT
Acetaminophen (i.e. Tylenol/APAP) Ibuprofen (i.e. Advil/Motrin) (These medications may also be given for fever over 101 F if dismissal will be delayed and student is very uncomfortable.) FOR DIGESTIVE PROBLEMS
Antacid (i.e. TUMS/Mylanta), Bismuth (i.e. Pepto-Bismol) FOR COLDS/ALLERGIES
Cough medicine (i.e. Tussin) Dipenhydramine (i.e. Benadryl) Non-drowsy Cold Medicine (i.e. Sudafed) Cough drops FOR WOUNDS
Hydrogen Peroxide Isopropyl Alcohol Bactine Witch Hazel Hand Sanitizer First Aid/Burn Cream or Gel Calamine Preparation Sunscreen Saline Solution/Eye Wash Salted Water Vaseline I understand the School Nurse may decline to administer an OTC medication if, in his/her judgment, other relief measures should be
attempted first or if further medical evaluation may be needed for the symptoms.

Parent/Guardian signature ___________________________________________ Date _________________
Parents/guardians are requested to contact the School Nurse directly if they have any questions or concerns about medication administration during
the school day. Each School Nurse will communicate specific protocols for medication administration for that particular school. Some OTC
medications may not be stocked in each school, depending on the usual needs/abilities of the students.

PLEASE COMPLETE REVERSE SIDE

Source: http://www.palmerschools.org/Forms/student%20health%20information%20sheet%20for%20PHS.pdf