Important: this form must be submitted each school year

Narragansett High School
School Health Office Information
Address____________________________________________________Phone #______________________
Medical Problems (ie. Asthma, heart disease)___________________________________________________
If severe allergic reaction (List treatment)_____________________________________________________
Example: Benadryl, EpiPen- parent must supply medication along with parental permission form and
physicians order. (Please refer to the medication policy in the student/parent handbook)
My child wears glasses: (yes or no) __________ Contact lenses__________

I authorize the administration of a non-aspirin medication to my child at the discretion of the
school nurse during school hours for headache, pain or fever. (Please check)
Tylenol ______ Ibuprofen (generic Advil)_________
Parent/Guardian signature_______________________________________________
(Permission is acceptable for one year and must be renewed annually)

My child takes the following medications at home (name of medication/dosage)_______________________ _______________________________________________________________________________________ I authorize that my child may self –medicate with his/her prescribed inhaler. Physicians order to accompany medication. Permission acceptable for one year and must be renewed annually. Parent/Guardian Signature__________________________________
Mother’s Name____________________Business#_____________Cell#______________Email__________
Father’s Name_____________________Business#_____________Cell#______________Email__________
Restraining order (yes or no)________ (If yes, a copy of the order must be provided to the office)
Custody Agreement: (check one) N/A _____Sole_____ Dual ____Guardian Signature__________________
Physician:__________________________________Hospital Preference_____________________________
Please list the names of relatives or friends you authorize to take your child home in case of emergency
1. Name_________________________________________Telephone #’s____________________________
2. Name_________________________________________Telephone #’s____________________________
Please list any further comments, concerns, or information________________________________________
Parent/Guardian Signature___________________________________________Date_________________


Secure the future™,

Secure the FutureCare and Support for Women and Children with HIV/AIDSSecure the FutureCare and Support for Women and Children with HIV/AIDSBRISTOL-MYERS SQUIBB: A GLOBAL COMMITMENT TO HIV/AIDSSince the discovery of the HIV virus in the early 1980s, HIV/AIDS has grown into a global pandemic, while thefield of HIV/AIDS research has moved into a new era of therapeutic advances. Within this co

Microsoft word - product list.doc

G. D. LABORATORIES (INDIA) PVT. LTD. PWD REST HOUSE ROAD, NOHAR-335523 Product List COMPOSITION Albendazole IP 400 mg Colour: Lake of Sunset Yellow Amlodipine Besilate BP Eq to Amlodipine 5mg Colour: Iron Oxide Red Azithromycin USP (As dihydrate) eq to Anhydrous Azithromycin 250mg Colour: Lake of Ponceau 4R Azithromycin USP (As dihydrate) eq to Anhydrous Azithromycin 500mg Colou

Copyright © 2008-2018 All About Drugs