Summer School Medical Information Sheet

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Summer School Medical Information Sheet
Student’s Name: ______________________________
Is general health good?  Yes
 No, explain below:
If applicable, please check:
____ Convulsion Disorder
____ Significant allergies
____ Food restrictions
____ Visual Problems
____ Wears glasses
____ Contact Lenses
____ Hearing Problems
____ Asthma (
Prescribed inhaler may be kept by the student & self-administered if the physician or parent indicates this
need in writing and considers the student sufficiently responsible.)
Please explain any above:
Specific medical problems:
Restricted physical activities:
My son/daughter is allergic to:
His/her allergic reaction is:
My son/daughter is currently taking the following medications:
ALL medication must be labeled with the student's name and brought to the School Nurse
If applicable, please turn in a completed Medication Procedure Form 3 to the clinic.
Prescription medication must come in a bottle from the pharmacy.
The medication label must include the
doctor's name, name of medication, and dosage. Parent/guardian MUST inform the school of any changes in
Over-the-counter medication must be labeled and turned in to the School Nurse accompanied with a note
from parent/guardian.
Parent/Guardian Signature


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