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Microsoft word - form1 med consent 1314.doc

lth Services
Medical Consent for Student
To Be Completed by PARENT/GUARDIAN (Please print clearly in ink.)
Student Cel #: (______)_____________________
Student Email: ________________________@_______________________
Student Name LAST:
__________________________________ FIRST: __________________________  M or  F DOB: ___/___/___
Home Address: Street _____________________________________________ City/Town ______________________ Parent/Guardian Ful Name: _________________________________ Parent/Guardian Ful Name: ____________________________  Other _________________________________________  Other _________________________________________ Home Tel #: (______)_______________________________ Home Tel #: (______)________________________________ Work #: (______)_______________________________ (______)________________________________ (______)________________________________ Email: ____________________________@__________________________ Email: ____________________________@_________________________ (Email addresses wil be published in the Thayer Academy Handbook, along with home addresses, unless you indicate otherwise).
Alternate emergency contacts, when parent(s) cannot be reached: 1. _____________________________________________ relationship: _______________________ Tel #: _______________________________ 2. _____________________________________________ relationship: _______________________ Tel #: _______________________________ HEALTH INFORMATION
Physician: _______________________________________ Office #: (_____)_____________________ Dentist: _________________________________________ Office #: (_____)______________________ Health Insurance Co: __________________________________ Policy #: ________________________
Health/medical concerns [Be sure to include any health changes since last year. Note: any history of life-threatening al ergies,
asthma, or serious medical conditions such as diabetes wil be shared as needed with faculty, staff and coaches].  Allergies to: ________________________________ Describe reaction ___________________________________ Requires Epi-Injector*
 Asthma  Requires Inhaler*
 Diabetes*
 Heart condition _______________________________________________
 Orthopedic injuries  Seizures ______________________________________________________  Mental health concerns:  Depression  Anxiety  Other health-related educational concerns (e.g.  ADD/ADHD) Additional information: ________________________________________________________________________________________________________  Daily/Current medications*: ________________________________________________________________________________________________
 Recent international travel (specify): _______________________________________________________________________________________ *Additional authorization forms are required for Epi-Injector, Inhaler or other medications except ibuprofen and acetaminophen.
CONSENT for Ibuprofen or Acetaminophen at School
I give permission for my child listed above, to receive the following medications, administered by the school nurse as needed for minor discomforts such as headache (not related to acute head trauma), minor muscle aches, or menstrual cramps.  (Parent initials: __________) Tylenol or generic acetaminophen, per weight, not to exceed 1000 mg oral y.
 (Parent initials: __________) Motrin or generic ibuprofen, per weight, not to exceed 400 mg oral y.


In an emergency involving my child, I understand that every effort will be made to contact the parents, the physician, or other list individuals. Thayer Academy’s faculty/staff (athletic trainers, nurse, coaches) or its representatives are hereby authorized to: 1. use their best judgment and discretion in handling the emergency; 2. activate EMS to transport my child to the nearest hospital as necessary; 3. photocopy this form, which is considered the same as the original, and send with the student. I authorize emergency treatment to be initiated as needed. I agree to be responsible for the payment of any medical treatments administered to my child, in connection with injury, accident or illness that may occur while my child participates in any Thayer Academy program, which he/she is hereby granted permission to do. Parent/Guardian Signature: X _______________________________________________________
Printed Name: ________________________________________________________ (Submit form to: School Nurse, Thayer Academy, 745 Washington St., Braintree, MA 02184 or via fax: # 781-848-7261.)



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