Pinkertonacademy.net

5 PINKERTON ST., DERRY, N.H. 03038-1501 Ms. D. M. Chimento, BSN, RN, NCSN School Nurse Mrs. L. S. Roy, RN 2010-2011 Health Information and OTC Medication Permission
rst) ______________________________
This form MUST be PRINTED and SIGNED by a parent/guardian. The signature is REQUIRED for nursing staff to provide
ANY medications, including over-the-counter acetaminophen or ibuprofen, to students (per NH Board of Nursing).
Electronic signatures CANNOT be accepted. NO medications will be provided without written parental permission.


Student name: __________________________________ ID #: ____________________ DOB _______ - _______ - ________
(PLEASE PRINT)
Does your student have: ASTHMA? ______ DIABETES? ______ SEIZURES? _____ NEED an EPI-PEN? ________

Please update any changes in health information during the past year:

Allergies: _____________________________________________________________________________________________

Surgeries: _____________________________________________________________________________________________
NAME OF STUDENT: (Last)_________________________________ (Fi
Current medications: _____________________________________________________________________________________
Other problems/concerns (physical or emotional) or restrictions: ________________________________________________
________________________________________________________________________________________________________
~~~~~ PLEASE NOTIFY THE NURSING STAFF (437-5218) OF ANY HEALTH INFORMATION CHANGES THROUGHOUT THE YEAR ~~~~~
Current Physician/PCP: _________________________________________ Tel. # _____________________________________

Parent contact (name): ________________________Home_______________Cell________________Work________________
Second contact (name): _______________________Home_______________Cell________________Work________________

Only the OTC (over-the-counter) medications listed below are provided by the Health Services nursing staff. All other medications
must be provided by parents (for additional information please see Health Services page at ).
I give permission for PA nursing staff to provide one (or more) medications listed below during the current school year:
SIGN BELOW for EACH OTC med. authorized
400 mg. (two tablets) ____________________ This form replaces the “Emergency Form” used in the past. Please mail it to Health Services as soon as possible. Please update biographical and contact
information via your Edline account (or by calling Student Information Services). In event of an emergency, the nursing staff will contact you as soon as possible, but will
not delay accessing emergency care at the local emergency room. Whenever possible, this form will accompany your student. The nursing staff may also contact your
child’s health care provider regarding immunizations, medications, etc. and follow their instructions as needed and make whatever arrangements appear necessary for
the health and safety of your student (10/09).

Source: http://www.pinkertonacademy.net/departments/healthservices/documents/otc_med_permission_form.pdf