MJS - Outdoor Education - Medical Information Form
Memorial Junior School - Authorization for Medical Treatment of a Minor Temporarily Separated from Her/His Parent/ Guardian - Must be completed by September 30, 2019
Sign in to Google to save your progress. Learn more
Email *
Please review the following medication guidelines:
All medications must be provided to the school nurse by October 14, 2019 in its original packaging. Parent/Guardian may also bring medication to the Orientation Night (in Fall 2019), as the MJS Nurse will be present.

A completed "Request for Administration of Medication by the School Nurse/Registered Nurse" form must accompany each medication and must be signed by both the parent/guardian and the student’s physician.

Board of Education policy stipulates that students who are permitted to self-administer their medication (for asthma, bee stings, or any another potential life-threatening illness) must have their parent/guardian complete the "Request for the Self Administration of Medication" form. If an Epi-Pen is needed, an additional form entitled “Emergency Administration of Epinephrine via Epi-Pen” is also required.

Medication Forms are located in the MJS Health Office, MJS website, or in the MJS Main Office, over the summer. If you have any questions, you may contact our MJS Nurse (Ms. Gioia) at 973-515-2431 during the school year.
Please complete the following form by September 30, 2019, in order for your child to attend the 2019 MJS Outdoor Education Experience! The contents of this form are kept confidential and will be managed by the Program Coordinator and MJS Nurse.
Student-Last Name *
Student-First Name *
Student-Date of Birth *
Student-Address *
Home Phone # *
Parent/Guardian #1 - Last Name *
Parent/Guardian #1 - First Name *
Parent/Guardian #1 - Cell Phone # *
Parent/Guardian #1 - Work Phone # *
Parent/Guardian #2 - Last Name *
Parent/Guardian #2 - First Name *
Parent/Guardian #2 - Cell Phone # *
Parent/Guardian #2 - Work Phone # *
Emergency Contact #1 *
Phone # *
Emergency Contact #2 *
Phone # *
STUDENT MEDICAL SERVICES AUTHORIZATION
Physician Name *
Phone # *
STUDENT INSURANCE INFO
Company Name *
Group # *
Identification # *
STUDENT MEDICAL NEEDS
Student Allergies (medications, insects, foods, etc.) - IF NONE, TYPE "N/A" *
What are common symptoms?
What are treatment options? (i.e. Epi-Pen) *
Medical Conditions - IF NONE, TYPE "N/A" *
Please list any medication(s) the student will be taking during Outdoor Education. A doctor’s note is required and must be provided with each medication. Medication Forms are located in the MJS Health Office, MJS website, or in the MJS Main Office.
Food Restrictions: (low fat, vegetarian, lactose intolerant, gluten free, allergies, etc.) - IF NONE, TYPE "N/A" *
When was the student's most recent Tetanus shot? *
You have permission to give my child Tylenol *
You have permission to give my child Benadryl. *
Authorization for Medical Treatment of a Minor                                    
Temporarily Separated from Her/His Parent(s) or Guardian(s)
If I/we cannot be reached, I/we authorize the MJS Administrator or Brenda Talbert (Outdoor Education Coordinator) to authorize medical services for my child. This includes: consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor, at a recognized medical facility, under the general or special supervision of a licensed physician or surgeon. *
PARENT/GUARDIAN ACKNOWLEDGEMENT
This eSignature will serve as your official consent and authorization to all terms and conditions, as stated, on this form. *
Required
eSignature *
This authorization will be in effect while the student attends the Memorial Junior School - Outdoor Education Experience from Wednesday, October 16 - Friday, October 18, 2019.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Hanover Township School District. Report Abuse
Google Forms