Whitin Student Medical Information Form
Please complete one form for each student you have at Whitin.
(There are separate forms for each school)
Please contact your School Nurse, Kristin Gauthier with any questions or concerns.
kgauthier@uxbridge.k12.ma.us

Reminder: Prescription medications and OTC (allergy/cold medications) must be accompanied by a doctor’s note, a signed parental consent form and the original pharmacy container.  Consent forms are available in each school.
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Student Name, (Last, First) *
Grade *
Physician's Name
Student Address *
Parent/Guardian Name *
Parent Email *
Parent/Guardian Address *
Parent/Guardian Phone Number *
Parent/Guardian Alternate Phone Number, if applicable
Parent/Guardian Name *
Parent Email:
Parent/Guardian Address
Parent/Guardian Phone Number
Parent/Guardian Alternate Phone Number, if applicable
Student Medical Conditions:
Allergies:
Does your student require an EpiPen? *
Will your child require a Nut-Safe table in the cafeteria?
Clear selection
Medications currently taking:
Is your student prescribed an inhaler or nebulizer? *
If yes, will it be sent to school?   If it will be send to school please have physician send medication order to school.
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Permission to Administer Over the Counter Medications  Administration of  Over the Counter Medications in school is based on protocols developed by the school nurse, school physician and school administration.  Please check the medications below that you give permission for your child to receive during the school day.  Students are not allowed to carry medications in their backpacks unless authorized by their physician  (written order must be on file with the school nurse)
I give permission to the Uxbridge Public Schools to release medical information  to my child's bus driver and staff working with my child. *
I give permission for State Mandated BMI (Body Mass Index) measurements in grades 1,4,7, and 10 to be done by the school nurse,  see  www.mass.gov/massinmotion for further information. *
If the school is unable to contact me in case of serious accident or medical emergency, I authorize the school to provide Emergency Medical Services. *
Please type parent/guardian name below to confirm all of the above information is correct. *
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