Salem Public Schools Student Data and Permission to Treat Form for School Nurse
Student Last Name _____________________First ___________________School _______________________
Home Address ______________________________________ Date of Birth ___ / ___ / ___ Grade ________
Parent or Guardian ___________________________
Home Phone ( ) __________________________
Cell Phone ( ) _________________________ Work Phone ( ) ___________________________
Parent or Guardian ___________________________ Home Phone ( ) __________________________
Cell Phone ( ) __________________________ Work Phone ( ) ___________________________
Emergency Contact: ___________________________ Phone ( ) ________________________________
Emergency Contact: ___________________________ Phone ( ) ________________________________
MEDICAL/EMERGENCY INFORMATION Family Doctor _______________________________________ ( ) ______________________________
Family Dentist _______________________________________ ( ) _____________________________
Allergies _________________________________________________________________________________
Medical Concerns __________________________________________________________________________
Daily Medications __________________________________________________________________________
Health Insurance Provider ____________________________________ Policy # ________________________
In case of severe emergency and I can not be reached, I give my permission to NSMC to render treatment to the above named student. Ambulance takes emergency cases to NSMC only. Parent/Guardian Signature: ______________________________Date______________ PERMISSION TO TREAT
I give permission to the school nurse to administer the following medications to my child according to the established protocols. I have crossed out any products that I do not wish my child to receive.
Acetaminophen (Tylenol)
o As needed for minor pain or fever subsequent to nursing assessment.
Bacitracin Ointment
o As needed for cuts, scrapes, etc. 1 – 3 times a day
Calamine Lotion Hydrocortisone Cream 0.5%
o As needed 3 times daily to relieve itching associated with minor skin irritations and rash
Pramoxine HCL Wipes
o As needed for the temporary relief associated with insect bites, hives, (sting relief) Benadryl Elixir (diphenhydramine hcl)
o As needed for relief of variety of hypersensitivity reactions
All other medications require a written order from a licensed prescriber (physician, dentist, nurse practitioner) and written parental permission To the best of my knowledge, my child has no allergy/sensitivity to any of the above named products. I give permission to the school nurse to share with appropriate school personnel information relative to any described health concerns. Parent/Guardian Signature: ________________________________________________
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SÃO FRANCISCO E AS ESTRUTURAS* Tempos de transição são sempre também tempos em que se questionam as estruturas recebidas do passado. Elas entram em crise, são contestadas na medida em que parecem opor-se ao dinamismo da nova vida, ou são defendidas em nome de valores tidos por inalienáveis. Desde que se entenda a realidade social, política e eclesial por algo de orgânico, não se pod