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Salem public schools student data form

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______________
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: ________________________________________________

Source: http://spsdistrict.vt-s.net/Pages/SPS_DistHealth/Revised_Data%20_PTT_eng.pdf


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