Sturgis Charter Public School-West 2023-2024 Emergency Medical Form For Returning Students

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Please complete this emergency medical form for your child returning to Sturgis West in one sitting as you can not edit or change the information after you submit the form. If you need to make changes after you have submitted the form, please contact the school nurse. Please be assured that your responses will only be seen by the school nurse, are password protected, and will only be shared with school staff by the school nurse on a need to know basis (only when they will be providing direct supervision to your child)

Email *

Student's First Name: *

Student's Last Name: *

Student's Date of Birth: *

YYYY

My child is in: *

10th grade

11th grade

12th grade

Does your child have any allergies? *

Yes

If yes, what is your child allergic to?

Does your child require an Epipen for their allergy? *

Yes

If you answered yes, please be sure the nurse has a copy of your child's allergy action plan on file as it is a requirement. The link to this form is below.

https://drive.google.com/file/d/1vpyXmkCIzd6di4kuMq_RLu8tnM6i-cQR/view?usp=sharing

Will your child need to carry an inhaler during the school day to use as needed for asthma or breathing difficulties? *

Yes

If you answered yes, please be sure the nurse has a copy of your child's asthma action plan on file as it is a requirement. The link to this form is below.

https://drive.google.com/file/d/1IzIg73G4A7v0BZXYbPpRpg1g_kM-Pcxu/view?usp=sharing

Please indicate any updates to your child’s medical history from last year (.i.e. primary care physician, insurance changes, new medical concerns etc.). If no, please type "none". *

Do you have any new or updated mental health concerns related to your child? (i.e. new diagnosis, medication, hospitalization, started therapy, etc.) If yes, please explain. If no, please type "none".
*

Please list all medications your child takes regularly (including prescriptions, supplements, and medicated creams/lotions). This is important information in the event of an emergency as well as for the nurse to be able to provide informed care to your child. If your child does not take any medication at all, please type "none". *

My child has the following health insurance coverage...

MassHealth

Private insurance through parent/parent's employer/self pay

Clear selection

Would you like to receive information about Sturgis' free and reduced lunch program. Our program is funded by the school and can help with expenses related to bus transportation, graduation, sports fees, and other programs.
*

Yes

Non-Prescription Medication Consent:

The school nurse can administer acetaminophen, ibuprofen, calcium carbonate, and cough drops during the school day with your permission. Please note that the if your child takes seven doses of any of these medications you will be notified and asked to sign and return the Non-Prescription Medication Consent and Order form to the school nurse. The school nurse will then forward the form to your child’s physician to obtain a medication order for the medication if the nurse deems it appropriate.

Please select the medications you give permission for the school nurse to administer to your child during the school day.
*

Tylenol (acetaminophen) 325 mg-650 mg (1-2 tablets) every 4-6 hours

Motrin/Advil (ibuprofen) 200 mg-400 mg (1-2 tablets) every 6-8 hours

Tums (calcium carbonate) 500-1000 mg (1-2 tablets) as needed

Cough drops 1-2 as needed

I do not give my permission for any of the above medications to be given to my child during the school day.

Required

I request the above medication(s) to be administered to my child under certain conditions. If so, please list your conditions. If you have no conditions leave this question blank.

My child has my permission to use alcohol based hand sanitizer for the purposes of sanitizing their hands during the school day in addition to using soap and water to wash their hands. *Hand hygiene is a strongly recommended protective measure against seasonal illnesses. *

Yes

I consent for my child to self administer Covid-19 antigen testing under the supervision of the nurse when multiple symptoms of Covid-19 are present.
*

Yes

Emergency Contacts:

Please list someone other than yourself to be called in case of an emergency and the school is unable to reach you. Type in the text box below the person's name, relationship to your child, and phone number with area code.

*Emergency contacts listed below should be local and within driving distance to pick up your child from school in necessary.

Emergency Contact # 1 Name *

Emergency Contact # 1 Phone Number *

Emergency Contact # 2 Name *

Emergency Contact # 2 Phone Number *

Parental Releases:

My signature below gives permission for the following:

1. The school nurse to provide first aid and medical treatment to my child for any illness or injury that occurs during the school day.

2. The school nurse to share relevant information regarding my child's health with appropriate school personnel. A copy of this information may be given to emergency service personnel in the event of an emergency.

3. The school nurse to exchange information with my child's physician for the purposes of treatment, referral, and attendance coordination (e.g. to request notes for absences when your child was seen by their physician, to request orders for prescription medications that need to be administered during the school day, to relay assessment results after an emergency or injury etc).

4. The nurse to administer medication as ordered by my child's physician.

5. I understand that in case of illness or injury to my child, the school will make every effort to notify me. If I can not be reached, the school will notify the emergency contacts listed above.

6. In the event of an emergency, permission for my child to be transported via ambulance to the nearest emergency care facility to receive emergency treatment.

7. In the event a parent/guardian can not be reached in an emergency, permission for the attending physician, hospital, or other emergency care center facility to secure proper treatment for my child.

8. I acknowledge that I understand that it is the policy of Sturgis Charter Public School that no student shall carry any medication on their person while on school grounds. This includes leaving medications in a locker or backpack. This includes over the counter medication, prescription medication, supplements, and creams. There are certain exceptions to this including emergency medication such as Epipens and inhalers, however, the school nurse must have an active plan with the student and family.

By clicking here I agree to the statements above.

Required

Parent/Guardian, please type your full name and the date below. This will serve as your digital signature. *

Send me a copy of my responses.

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