Nurses’ Packet- New Students

Nurses' Packet - New Students

ALLERGIES: Please list all of your child’s Allergies and reactions. e.g. Food, Insects, Seasonal allergies.

Does your child have an epinephrine auto injector? (Epipen™, Auvi-Q™) ___Yes ___ No If yes, your child needs an order from his/her doctor and a pharmacy labeled epinephrine auto injector sent into school.
Has your child ever needed to receive the epinephrine auto injector? ___Yes ___ No

Current Medications Given at Home: If you have a long medication list please continue on page 3.

Medications to be given at School: If you have a long medication list please continue on page 3.

I give permission for a School Nurse to administer the following over the counter medications as needed:
You will need to send in a doctor’s order with a pharmacy labelled container of the Diastat.
My child may participate in the following state mandated screenings: I understand that these are only screenings and any abnormal findings will be referred back to me for follow up with my child’s Primary Care Provider.

I also understand hearing screenings are not done at CCCBSD and should be done at my child’s primary care physician, specialist’s office or our home school district. Please will forward the results of the hearing screening to the School Nurse. Please check all that apply.

List of current Primary Care Provider and Specialists my child sees:

By signing below, I am granting permission for the School Nurse to give my child the above prescription, and over the counter medications, that I have checked off as YES. I also acknowledge I need to contact my child’s health care provider to obtain orders for all prescription and any over the counter medications not listed on page 2. I will keep the school nurse appraised of any medication changes. When my child is off campus for a community outing or a field trip I understand medication will be administered by trained school personnel, designated by the School Nurse.

1) Past Medical History:

Birth to Toddler:
Complications if any: For example, born at 24 weeks, on ventilator, seizures, in the NICU for 4 months, failed newborn hearing test.
Feeding Issues:
For example, difficulty breastfeeding or bottle feed, frequent vomiting, refused solid food, poor weight gain, G-tube placed. Did your child work with a feeding specialist?
Developmental milestones:
On time, delayed. Please write a brief summary.


ALLERGIES: Please list all of your child’s Allergies and reactions. e.g. Food, Insects, Seasonal allergies.

Surgeries: Past Surgeries

Upcoming surgeries or procedures.

Current Medical Diagnosis:


Gross Motor Skills:

Has your child had an occupational therapy evaluation and or treatment.
(If so please attach a copy of the latest evaluation and report )

Oral Feeding

G-tube feedings:

Communication/Speech-language information:

Does the student currently do the following? If so, how?

Speech-language skills- provide a copy of most recent evaluation(s).

Please use this area to add additional information:

Please attach the most current reports from all of your child’s medical and therapy specialists. If you have any questions please contact the Program Director.

Thank you for sharing your information. The more information you share, the better we can understand your child’s individual needs.
I, _________________________________ Parent of _________________________________ have filled out this packet to the best of my knowledge. . I give permission for the School Nurse to administer to my child, the over the counter medications I answered “Yes” to on page 2.
I understand, any changes to medications, treatments or feedings, will require a new medical order to be sent into the School Nurse’s office.