Medical Alert Form

Student allergies (if you checked the "yes" box please complete # 1-2, and page 2 #A & #B) *
1. Please list and describe allergies or reactions to:
Student has asthma *

Injuries, Illnesses and Surgeries

Please list any severe injuries, illnesses or surgeries:

Hospitalized? *

Additional Information

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 *
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