Student Medication Or Medical Treatment - Westmount Charter School
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2WESTMOUNT CHARTER SCHOOL
ADMINISTRATION OF PRESCRIPTION MEDICATION AND/OR MEDICAL TREATMENT FORM
Student Information
Student’s Name:
___________________________________________________
Grade/Class: __________________
Student’s Alberta Health Care Number:
___________________
Student’s Date of Birth: __________________
Home Address:
______________________________________________________________________________________
Contact Information
Mother’s Name:
____________________________
Father’s Name: ____________________________________
Home Phone:
____________________________
Home Phone: ____________________________________
Work Phone:
____________________________
Work Phone: ____________________________________
Cell Phone:
____________________________
Cell Phone: ____________________________________
Emergency Contact Name:
__________________________________
Phone: _______________________________
Physician’s Name:
__________________________________
Phone: _______________________________
Severe Allergy Alert Information
This portion of the form should be completed only if the student has a severe allergy. A severe allergy is defined as
a severe allergic reaction or anaphylactic response which, if left untreated, can lead to sudden death.
Allergen(s):
_________________________________________________________________________________________
Symptoms of a reaction:
________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Emergency Action Plan:
___________________________________________________________
(attach separate sheet if needed)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Medication/Treatment Information
Medication prescribed:
__________________________________________________________________________________
Purpose of medication: __________________________________________________________________________________
Medication dosage, time of administration and procedure for administration: _________________________________________
_______________________________________________________________________________________________________
Medication storage and safekeeping requirements: _____________________________________________________________
_______________________________________________________________________________________________________
Specifics of treatment required, if any: _______________________________________________________________________
_______________________________________________________________________________________________________
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