Skip to content
Content starts here

Policies » Section J: Students » JLCD-R/JLCE-R: Annual Health Information/Parental Permission for Medication

Policy Date: 05/09/2017

Download Policy Now

Your child’s health and safety is of utmost concern to the school staff. It is essential that the school nurse be notified when a child is diagnosed with an allergy or other medical condition or begins taking medication at home. Please call the school nurse whenever you have a concern or new information relative to your child’s health and safety.

Student’s Name:             Birth Date:    Grade/Teacher:

Allergies (to food, insect stings, meds, etc.):

Medical concerns, please check any that apply:
Asthma _____ Diabetes _____ Seizures _____ Head injury _____ Heart condition _____
Urinary or Kidney condition _____ Skin problems ____ Depression _____ Anxiety _____
Attention Deficit Disorder (ADD/ADHD) _____ Frequent headaches _____ Other ______
Frequent ear infections _____ Hearing problems _____ Vision problems _____
Bowel problems _____ Frequent stomachaches _____ Frequent nosebleeds _____
Has your child had any illness or injury over the summer?

Indicate the dates of any immunizations your child has had during the past year.
Tetanus (Tdap) __________ MMR __________ Hepatitis B __________ Varicella (Chickenpox)_________
Please follow-up with written documentation from your provider.

Have there been any changes in your family and/or problems you wish to share with the school? Feel free to call or send a confidential note?

Explain any physical limitations or disability your child has and any modification or restriction necessary to accommodate your child’s health or safety.

Medical aids: glasses/contacts _____ hearing aids _____ crutches _____ braces _____ wheelchair _____
other If other, please explain:

Medications: please contact school nurse to make arrangements for medications in school.
At school: dosage time reason
dosage time reason
At home: dosage time reason
dosage time reason ________________

Physician’s Name: Tel #:
 I understand that there may be times the nurse may need to speak with our physician.
 I would like more information about low cost health insurance for my child.

Parent/Guardian Signature: Date:

Auburn Village School
Parental Permission Form for Over-The-Counter Medications

Dear Parent/Guardian:
The New Hampshire School Nurse is a Registered Nurse who manages School Health Services to facilitate and strengthen the educational process for all students within the school setting. Although not encouraged, I realize that Over-The Counter (OTC) medications are sometimes appropriate and, in fact, necessary. Under the NH Department of Education administrative rule, Ed 311.02, parents may give written permission for a child to receive short-term OTC medication at school. A new form must be completed each year.
The decision to administer such medication/treatment is that of the School Nurse. Please understand that these will only be administered to relieve symptoms of occasional pain and/or discomfort and should not be used as a substitute for chronic health problems or to keep an ill child in school.
If your child seems to need any of these medications more often than occasionally or I have concerns regarding the use of any of these medications, I may request that you have a health care provider’s evaluation and authorization to continue giving the medication. You may be asked to provide a supply for your child as well; all medications must be delivered to school by an adult in the original container. Any medication left at the end of the year will be disposed of within one week of the end of school.

Below is a list of over-the-counter items available in the Health Office. Any other item must be supplied by the parent (original container, delivered by an adult). Please check those items that you authorize your child to receive:

Oral medications
 Acetaminophen (generic Tylenol), tablets dosage by age/weight
 Ibuprofen (generic Advil/Motrin) tablets dosage by age/weight
 Benadryl elixir/tablets, dosage by age/weight for significant allergy
 Antacid tablets (chewable)
 Chloraseptic type spray for minor sore throat
 Cough Drops

Topical medications for first aid
 Calamine/Caladryl lotion
 Hydrocortisone cream
 Antibiotic ointment (such as Bacitracin)
 Sting-kill insect bite swabs (Benzocaine 6%)
 Bactine and Burngel

Other (parents must supply):

Reason for use:

Thank you for your cooperation,
Jennifer Bernier
School Nurse

Child’s Name: Grade:

 My child has no known allergies.
 My child is allergic to:

Signature: Date:

Print Name: Relationship: