Important: this form must be submitted each school year

IMPORTANT: THIS FORM MUST BE SUBMITTED EACH
SCHOOL YEAR
Narragansett High School
School Health Office Information
Student______________________________DOB_______________Grade_______Advisor____________
Address____________________________________________________Phone #______________________
Medical Problems (ie. Asthma, heart disease)___________________________________________________
Allergies__________________________________Symptoms_____________________________________
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____________________________
Address_____________________________________________Relationship_______________________
2. Name_________________________________________Telephone #’s____________________________
Address_____________________________________________Relationship_______________________
Please list any further comments, concerns, or information________________________________________
_______________________________________________________________________________________
Parent/Guardian Signature___________________________________________Date_________________

Source: http://www.narragansett.k12.ri.us/nhs/clinic/SchoolHealthofficemedicalform.pdf