Medical Form

 

STRAYER MIDDLE SCHOOL 

OUTDOOR SCHOOL MEDICAL INFORMATION FORM



  • A school nurse will be present while your child is at outdoor school.  
  • If your child has a medical concern or must take a daily medication while at Outdoor School please fill out this form and return to the school nurse as soon as possible. 
  • All medication must be sent in the original labeled bottle from the prescribing doctor.  Please provide enough medication for the days your child is at Outdoor School, and keep all extra pills at home.  
  • All medications, prescriptions, and over-the-counter medication must be brought in by a parent and given to the school nurse the week prior to Outdoor School.
  • Please do not send vitamins or herbal medications unless medically necessary, and accompanied by a doctor’s note or prescription.
  • Please fill out this form even if your child has permission to take medications in school for the current school year. 




**PLEASE NOTE**

IF YOUR CHILD HAS A DOCTOR’S NOTE AND IS NOT ABLE TO TAKE PHYSICAL EDUCATION CLASS--THEY WILL NOT BE ABLE TO ATTEND OUTDOOR SCHOOL WITHOUT A NOTE FROM THE DOCTOR CLEARING THEM.  






STUDENT NAME____________________________________________D.O.B.____________


HEALTH CONCERN(S):_______________________________________________________


______________________________________________________________________________


ALLERGY (FOOD OR INSECT)_________________________________________________


DOES YOUR CHILD REQUIRES AN EPIPEN OR AUVI-Q?       

YES     / NO

DOES YOUR CHILD REQUIRE A RESCUE INHALER?              

YES     / NO

DO YOU WANT YOUR CHILD TO CARRY THEIR EMERGENCY MEDICATION WHILE AT OUTDOOR SCHOOL?

YES     / NO


NAME OF MEDICATION

DOSE

TIME (AM/LUNCH/PM/PRN)

*PLEASE SPECIFY TIME
















**ALL MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER**


The school doctor has written standing orders for the following medications to be given by the school nurse.  Please circle each medication that may be given to your child while at Outdoor School (Generic equivalent products may be provided). 

Advil

Antacid tablet

Benadryl (emergency only)

Tylenol

Hydrocortisone cream

Sting Relief

Burn cream/spray

Caladryl lotion

Moisturizing eye drops


Parent Signature_________________________Print Name________________________Date_______


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