BALTIMORE COUNTY PUBLIC SCHOOLS Office of Health Services Consent for Administration of Approved Discretionary Medications and Health Contact Information Student Name:______________________________________________________ Date of Birth:___________________ School:_______________________________________________ Grade /Teacher:______________________________ Allergies (include medication allergies): ______________________________________________________________ List all medications your child receives on a regular basis: _______________________________________________
Medical/Health Problems: Check all that apply
Other (describe) ____________________________________
Is there a health problem that would prevent full participation in the school program or physical education program?
I would like the following medication(s) made available to my child: (please check) For Headache/Fever/Burns/Earache/Muscle Aches/Pain/Menstrual Cramps For Upset Stomach (age 12 and older/age 9 for menstrual cramps) (like Tums) For Mild Allergic Reactions For Coughs/Sore ThroatsFor Diaper Rash I do not want any medication given to my child in school. Contact Information
Parent/Guardian 1 Name: __________________________ Parent/Guardian 2 Name: _____________________________
Parent/Guardian 1 Home Phone: ____________________ Parent/Guardian 2 Home Phone:________________________
Parent/Guardian 1 Cell: ____________________________ Parent/Guardian 2 Cell: _______________________________
Parent/Guardian 1 Work: ___________________________ Parent/Guardian 2 Work: _____________________________
Parent/Guardian 1 EMAIL: __________________________ Parent/Guardian 2 EMAIL: ____________________________
Parent/Guardian Home Address: ________________________________________________________________________
Persons to whom student may be released other than parent: Name: ____________________________________________ Phone Number(s):_________________________________
Do you need assistance in obtaining health insurance for your child? I understand that the above medications I have checked will be administered by the Registered Nurse/School Nurse in accordance with established protocols developed by the Chief Physician of School Health Services for the Baltimore County Department of Health and the Coordinator of Health Services for Baltimore County Public Schools. I understand that generic equivalent of medications may be used. My signature authorizes the release of my child to the persons listed on this page. _________________________________________________ ________________________________________________ Signature of Parent/Guardian/Eligible Student BALTIMORE COUNTY PUBLIC SCHOOLS BALTIMORE COUNTY DEPARTMENT OF HEALTH Towson, Maryland 21204 Baltimore, Maryland 21212 Annual Consent for Administration of Discretionary Medications and Health Contact Information
Dear Parent or Guardian: On the reverse side of this letter is a form that provides the school nurse with updated health information on your child, a list of persons to be contacted in the case of an illness or injury and a section to indicate your consent for the administration of certain nonprescription medications which are available, at no charge, for all students. This form must be filled out each school year.
The nonprescription medication program (called Discretionary Medications) is designed to alleviate minor discomforts and to prevent unnecessary early dismissals from school. These medications are approved by the Chief of School Health Services, Baltimore County Department of Health, and the Coordinator, Office of Health Services, Baltimore County Public Schools. Your consent must be obtained before any medication is given to your child. Only the Registered Nurse/School Nurse may administer these medications in accordance with established protocols. The consent form lists the medications which may be available. Please complete the consent form, and return it to the school nurse. Approved discretionary medications are intended for occasional use only. If your child requires any prescription or nonprescription medication on a regular basis, you must obtain a written order from your health care provider and supply the medications.
If you have any questions or would like further information, please contact your school nurse. Sincerely,
Bureau of Child, Adolescent, Reproductive and
School Health Baltimore County Department of Health
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