Medical Alert Form

Scholar Name *

Are you over the Age of 18 *

Yes

Parent/Guardian Name if Under the Age of 18

Student allergies (if you checked the "yes" box please complete # 1-2, and page 2 #A & #B) *

Yes

1. Please list and describe allergies or reactions to:

a. Medicines / drugs *

b. Foods / plants/ others *

c. Bee or wasp stings *

2. What happens if exposed to items allergic to? *

3. Recommended treatment if allergy is severe: *

4. What allergy medications is student currently taken? *

Student has asthma *

Yes

Injuries, Illnesses and Surgeries

Please list any severe injuries, illnesses or surgeries:

Injuries, illnesses, surgeries *

Age at the Time *

Hospitalized? *

Yes

Additional Information

1. Student does not have asthma or allergies but is currently taking medication for: *

2. What medications are taken daily? *

Administering medication during school hours:

Please notify the school if medication must be administered during school hours. Before any prescribed medication (i.e., a drug) or treatment may be administered to any student during school hours, the Governing Authority shall require a written statement from a physician/licensed health professional authorized to prescribe drugs ("prescriber") accompanied by the written authorization of the parent. Before any nonprescribed medication or treatment may be administered, the Governing Authority shall require the prior written consent of the parent along with a waiver of any liability of the School for the administration of the medication.

Signature of Parent/ Guardian *

clear

Date * +