Microsoft word - secondary heath update 11-12.doc

Secondary Student Health Update
Ankeny Community School District
Birth date ______________ Grade_________________________ Doctor_______________________________Hospital Preference_____________________________________ (Please complete this form, sign and return with registration.)
Does the student have:
Please explain "yes" answers
Allergies (food, environmental, medication) Medications(please list all medications) **For all medications given at school,
please complete form on the reverse side What immunizations has your child received in the past
_________________________________________________________________________________________ Note to parents: Health information is shared with school staff that has a legitimate educational interest regarding the student.
Ankeny Community Schools – Secondary Schools
Request for Giving Prescription and Non Prescription Medication at School
Student’s Name:____________________________________________________Grade:____________

School medications and health care services are administered following these guidelines:

-Parent signed and dated authorization to administer the medication. -The medication must be in the prescription container or the container in which it was purchased. -The medication label contains the student name, name of the medication, directions for use and date. -Annual renewal of authorization and immediate notification, in writing, of changes.
Permission for OTC medications:

Yes _____ No_____ Acetaminophen (Tylenol)–according to package directions Yes _____ No _____ Ibuprofen (Motrin, Advil)-according to package directions Students MUST bring their own supply of medication to school. The medication
will be kept in the nurse’s office and it MUST be in the original container.

Permission for prescription medications:
Name of Medication:
Medication Dosage:__________________________________________________________________

Dates to be Given:
Time to be Given: ____________________________________________________________________
Doctor Who Prescribed Medication: _____________________________________________________
Additional Information or Administration Instructions: ____________________________________
I request the above student be given the medication at school and school activities by qualified staff, according to the
prescription or nonprescription instructions and a record maintained. The student has experienced no previous side effects
from the medication. I further agree that school personnel may contact the doctor/prescriber as needed and that
medication information may be shared with school personnel who need to know.
I understand the law provides that there shall be no liability for civil damages as a result of the administration of
medication where the person administering the medication acts as an ordinarily reasonably prudent person would under
the same or similar circumstances. I agree to provide safe delivery of medication and equipment to and from school and
to pick up remaining medication and equipment.
Parent/Guardian Signature: __________________________________________ Date: ____________

For more information refer to board policy #504.32 at


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