School District, the following information must be completed for school personnel to dispense or ... _____ Delavan-Darien High School-FAX: 262-728-9713.
PARENT/GUARDIAN AND PHYSICIAN PERMISSION FOR PRESCRIPTION MEDICATION Name of Student _____________________________________________ Birthdate ________________________ School ________________________________________ Grade/Teacher_________________________________ To the Physician: According to the State of Wisconsin Medical Examining Board and the Delavan-Darien School District, the following information must be completed for school personnel to dispense or administer medications. Physician Name ___________________________________ Telephone number ____________________________ Medication(s) _________________________________________________________________________________ Dosage(s) ___________________________________________________________________________________ Time(s) of day to be administered________________________________________________________________ Length of time to be administered ________________________________________________________________ Special instructions ____________________________________________________________________________ I am willing to accept direct communication from the school nurse about dispensing or administering the medication. __________________________________________________________ Physician Signature
_______________________________ Date
To the Parent/Guardian: I request and authorize personnel from the Delavan-Darien School District to administer medication to the above named student. In the event more information is needed regarding this medication, I authorize the school nurse to contact my child’s physician.
Parent/Guardian signature ________________________________________________ Date _________________ Please fax this form to the following school: _____ Darien School-FAX: 262-724-4147 _____ Turtle Creek School-FAX: 262- 728-6951 _____ Wileman School-FAX: 262-728-6956
_____ Delavan-Darien High School-FAX: 262-728-9713 _____ Phoenix Middle School-FAX: 262-728-0359
PARENT/GUARDIAN AND PHYSICIAN PERMISSION FOR PRESCRIPTION MEDICATION Name of Student _____________________________________________ Birthdate ________________________ School ________________________________________ Grade/Teacher_________________________________ To the Physician: According to the State of Wisconsin Medical Examining Board and the Delavan-Darien School District, the following information must be completed for school personnel to dispense or administer medications. Physician Name ___________________________________ Telephone number ____________________________ Medication(s) _________________________________________________________________________________ Dosage(s) ___________________________________________________________________________________ Time(s) of day to be administered________________________________________________________________ Length of time to be administered _________________________________________________________________ Special instructions ____________________________________________________________________________ I am willing to accept direct communication from the school nurse about dispensing or administering the medication. ___________________________________________________________ Physician Signature
_______________________________ Date
Padres/Tutores: Yo solicito y autorizo al personal del Distrito Escolar Delavan-Darien para que le administren medicamento al estudiante arriba mencionado. En el evento que se requiera más información referente a este medicamento, yo autorizo a la enfermera escolar para que contacte al médico de mi estudiante.
Firma del Padre/Tutor ________________________________________________ Fecha _________________ Please fax this form to the following school: _____ Darien School-FAX: 262-724-4147 _____ Turtle Creek School-FAX: 262-728-6951 _____ Wileman School-FAX: 262-728-6956
_____ Delavan-Darien High School-FAX: 262-728-9713 _____ Phoenix Middle School-FAX: 262-728-0359
Start Date: ... after the finish date, or the medication will be destroyed in accordance with the law. I hereby release St. Paul Catholic School and their agents and ...
responsibility for monitoring the effects of this medication. Medication will be delivered to the school nurse or the designated person giving the ... Town ...
I request and authorize school personnel from the Delavan-Darien School District to administer medication to the above named student. Name of medication: ...
11 abr. 2002 - Name of Group: School Year of Group Activities: I desire that my son/daughter be allowed to travel to and from the events attended by the group.
for the management of chronic conditions must be accompanied by written ... All sample medications provided by a physician for school administration require ... vitamins, or over-the-counter health products) on their person; in their lunch box, ...
11 abr. 2002 - I desire that my son/daughter be allowed to travel to and from the events attended by the group listed above during this school year and to ...
our Physical Education classes will be participating in an in-house skating program. The skates will be delivered directly to the school. Due to insurance ...
Además libero a la escuela y su personal de cualquier responsabilidad resultante de cualquier efecto negativo que el medicamento pueda causar cuando ...
The authorization will be kept on file in the nurse's office. C. In the absence ... E. Any medication requiring administration longer than a two-week period must be.
The form must be filled out entirely including an explanation of the student's ... must avoid milk OR Must avoid all dairy products to prevent gas and bloating OR ...
Favor de escribir el nombre de su niño y indique si puede participar en la excursión. â¡ Yes, my child can attend. SÃ, mi niño puede participar. â¡ No, my child ...
4 jun. 2016 - In the Council Bluffs Community School District, students will be assigned a Google Apps Education Account that includes email and other Google services without written consent. Code of Conduct. By signing this form, I acknowledge that
I certify that I am the parent, legal guardian, or other person in legal control of the above identified student and request and authorize the school to administer the ...
11 ene. 2018 - I request and authorize that the above named student be administered the above identified medication in accordance with the instructions indicated above for the period commencing with the. _ day of. , 20_. _, through the day of. ,. 20_
Este permiso debe ser devuelto a la parroquia en la fecha señalada en la planilla de información sobre viajes, paseos o excursiones locales. En caso de que ...
En varias ocasiones durante el año escolar, los estudiantes de la Escuela Kelton tendrá viajes en autobús a los lugares y pueblos vecinos, incluyendo Pampa, ...
13 jun. 2018 - Nombre del estudiante: Fecha del reporte (mes/día/año):. Fecha en que el reporte fue dado al padre/tutor/padre sustituto: Fecha de nacimiento ...
Do noto restrain. â Do noto put anything in mouth. â Stay with child until fully conscious. â Record seizure. For tonic-clonic (grand mal) seizure: â Protect head.