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Harrison school district

EMERGENCY NOTIFICATION FORM

TO PARENT/GUARDIAN: To serve your child in case of ACCIDENT OR SUDDEN ILLNESS, it is
necessary that you furnish the following information:

EMERGENCY CALLS:

If not available, who else may we call for help?
PHYSICIAN: 1ST Choice

HEALTH INFORMATION: List any health conditions such as heart disease, epilepsy, severe allergies,
eye or ear problems, asthma, or any chronic conditions, etc:
*I, the undersigned, do hereby authorize officials of the Harrison School District to contact directly the persons named on this form and do authorize the named physician(s) to render such treatment as may be deemed necessary in an emergency for the health of said child. In the event physician(s), other persons named on this form or parents/guardians cannot be contacted, the officials are hereby authorized to take whatever action is deemed necessary in their judgment for the health of aforesaid child. I will not hold the School District financially responsible for the emergency care and/or transportation for said child. By signing this form below, you accept responsibility for informing school officials in writing of any health conditions which may arise after the date of this form which may require a modification of your child's educational program. As per Arkansas School Health Guidelines, published by the Department of Education, 1987, if a student's temperature is 102 degrees Fahrenheit or above, and there is an anticipated delay in transporting the student home, TYLENOL may be administered by school personnel if written permission has been previously obtained. As Harrison School District to administer TYLENOL (acetaminophen) to said child named above. This permission form will stay in the school's medical file while he/she is attending the Harrison School District. Without this form being signed and returned to the school, TYLENOL (acetaminophen) cannot be given. CONSENT FOR “OVER-THE-COUNTER” MEDICATIONS
Medication your child takes on a regular basis: It is the parent’s/guardian’s responsibility to send these medications to school, if they are needed on a frequent basis.
I give permission for my child,
, to receive
these “over-the-counter” medications as deemed necessary by the school
nurse/designee. I understand that the generic equivalent may be used in place

of brand names items.

For headache/fever/muscle aches/menstrual cramps:

Acetaminophen (like Tylenol) Ibuprofen (like Advil, Motrin) For mild cold symptoms:
For mild allergic reactions (such as hives, seasonal allergies):
For mild skin irritations:
Antiseptic/analgesic spray/gel/wash/hydrocortisone cream/medicaine swabs) Aniseptic/Analgesic:
Toothaches:
Eye irritation:

I understand the nurse/designee will administer the above medications. I
acknowledge that the District, it’s Board of Directors and employees shall be
immune from civil liability for damages from the administration of medications
in accordance with this form.

Source: http://harrison.k12.ar.us/UserFiles/Servers/Server_778832/File/Kindergarten%20Registration/4%20Emergenty%20Notification%20Form%20Consent%20for%20over%20the%20counter%20meds.pdf

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