ACP STUDENT ASTHMA/SEVERE ALLERGY FORM 2023-24

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MPVA PTO’s ACP is an inclusive program for all enrolled MPVA students. Special Need or Disability will never preclude a student from being enrolled. Families will meet with the Program Director and staff to determine any reasonable accommodations.

FORM 3 OF 4 OF ACP STUDENT REGISTRATION PACKET

TO BE COMPLETED BY PARENT/GUARDIAN FOR EACH CHILD BEING ENROLLED IN ACP PROGRAM.

All information regarding the MPVA ACP Program can be found on our website at mpva.membershiptoolkit.com/AFTERCARE-2023-PAGE1

Parents/Guardians: Enter preferred email on the line below:

Email *

CONFIDENTIALITY POLICY

The ACP program holds in the utmost regard the duty to uphold the confidentiality of all individuals connected with the Morning/After Care Program. Parent/Guardians must fully comprehend the implications inherent to this obligation. Parent/Guardians are required to acknowledge that the Confidentiality Policy extends not solely to their own student or family, but encompasses all students, families, and staff affiliated with the ACP program.

Any Parent/Guardian who divulges information deemed confidential, exerts undue pressure upon staff or other Parent/Guardians to acquire information beyond their purview, shall be deemed in breach of the Confidentiality Policy. Such actions will result in immediate removal of their student from the program.

STUDENT FULL NAME: *

STUDENT GRADE 2023-24 SCHOOL YEAR: *

Student Home Room Teacher (leave blank if unknown)

YES

DOES YOUR STUDENT TAKE DAILY MEDICATION OR USE A RESCUE INHALER?

CAN THEY ADMINISTER THEIR OWN MEDICATION

DOES YOUR STUDENT HAVE ANY SEVERE ALLERGIES?

DO THEY CARRY AN EPI PEN?

CAN THEY SELF ADMINISTER?

IF YOUR STUDENT CARRIES AN EPI PEN, BUT MAY HAVE NEVER USED IT OR ARE NOT COMFORTABLE WITH SELF ADMINISTERING, CHECK YES HERE:

If you would like to provide further information, please use the space below:

Please contact the Program Director at treasurer@mpvapto.com with any questions or concerns.

A copy of your responses will be emailed to the address you provided.

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