This will be an exciting year of learning,

growing, and staying healthy. I will be

visiting the school frequently and I am

easily reached for emergencies.

Trained health assistants and secretaries

will also work with the daily medical

cares of the children. Please contact me

if your child has special health concerns

or medical needs. By working together

we can keep your child safe and healthy

at school.

Thank you!

School Nurse

Please bring the attached forms on the FIRST DAY of school:

1. Immunization Form

2. School Physical Form

3. Vision Form

4. Dental Form

5. Health Information Enrollment Form

Rev. 2020

Emerson: Kim Mahlum (789-7678) Southern Bluffs: Sara Lieurance (789-7948) Hamilton/SOTA I: Michelle Rank (789-8441) Spence: Melissa Kujak (789-7684) Hintgen: Sara Lieurance (789-7948) State Road: Michelle Rank (789-8441) North Woods: Melissa Kujak (789-7684) Summit: Shelley Johnson (789-8427) Northside Elementary/MONT: Shelley Johnson (789-8427)

Welcome to Kindergarten

2020-2021

SCHOOL DISTRICT OF LA CROSSE

School Nurses/Schools: Shelley Johnson , 789-8427 Kim Mahlum, 789-7678 Lincoln Middle/SOTA II/Mont Central High Summit Elementary Emerson Elementary Northside Elementary/MONT 7 Rivers Community High ISP-Erickson Melissa Kujak, 789-7684 Logan Middle Michelle Rank, 789-8441 North Woods International Logan High Spence Elementary Hamilton Elem/SOTA I State Road Elementary Sara Lieurance, 789-7948 Longfellow Middle/LDI Hintgen Elementary Southern Bluffs Elementary

Health Guide

for Parents

When should your child stay home because of illness?

FEVER: greater than 100 degrees VOMITING: return 24 hours after vomiting DIARRHEA: return 24 hours after diarrhea RASH: rash that is open and draining or a rash with a fever STREP THROAT, IMPETIGO: return after 24 hours of treatment with antibiotic SCABIES, RINGWORM: must be treated before returning to school CHICKEN POX: child may return to school 5-7 days after onset of rash, with all sores dry and scabbed over

Please contact your child’s school if you have any questions regarding the above.

Please notify your child’s school if your child is absent due to illness or injury.

ILLNESS OR INJURY AT SCHOOL: Students who become ill or injured at school will be seen in the health room by trained staff. If your child is unable to return to class, a parent will be contacted. For your child’s comfort please make arrangements to pick them up as soon as possible.

If your child has a serious illness or injury that affects school participation, please notify your school principal or school nurse so a plan can be implemented to meet your child’s needs.

100

MEDICATIONS: Please give medications at home whenever possible. If medication is needed during the school day, the following is necessary.

Prescription Medication (1) A doctor’s signature with written instruction. (2) Written consent from the parent for the school to give the medication. (3) Medication is in a properly labeled prescription bottle.

Non-prescription Medication (1) Written consent from the parent with instructions for the school to give the medication. (2) Medication must be in the original container. Students may not carry medication at school with the exception of prescription

inhalers and epinephrine auto injectors with a doctor’s written permission.

Parents/guardians are requested to please deliver medication to the school office.

REMINDER:

A new medication form is needed each time the medication is changed.

A new medication form is needed for each school year.

School Medication/Procedure forms are available at your school office, school website or local clinic.

ENROLLMENT FORM AND EMERGENCY INFORMATION It is important for us to reach you if your child is ill or injured at school. Please complete the Annual Health Update Form and enrollment form from school, listing parent’s name with work and home phone numbers, along with two local emergency contacts. Call your child’s school with any changes throughout the school year. HEALTH AND SCREENING PROGRAMS Physical Examinations: It is recommended that Kindergarten students have physical, dental and vision examinations prior to school entrance.

Vision Screening: School District Nurses, along with parent volunteers, provide a vision screening program at your child’s school for students in Pre-school, Kindergarten, 1, 3 and 5. Your help would be greatly appreciated—call your child’s school office if you are interested in volunteering to help with vision screening.

IMMUNIZATIONS “IT’S THE LAW” s.252.04 Wis. Stats.

This law requires students through grade 12 to be immunized according to their age/grade by the beginning of the school year.

Immunization is a shared responsibility:

Parents are required to have their children immunized on schedule and keep accurate records. If a student is unable to receive

immunizations for medical, religious or personal conviction reasons, a waiver must be signed and given to the school.

Schools are required to keep records and review annually the Immunization Law.

When students do not meet the requirements of the law, parents are notified by a legal notice.

Helpful Hints:

Keep a copy of your child’s immunization record. Notify your child’s school each time your child receives an immunization.

Call your school office if you have any questions.

WISCONSIN IMMUNIZATION REQUIREMENTS 2020-2021

2-4 yrs 4 DTP/DTaP/DT 3 Polio 3 Hep B 1 MMR 1 Var

KG 4 DTP/DTaP/DT/Td 4 Polio 3 Hep B 2 MMR 2 Var 1st Gr 4 DTP/DTaP/DT/Td 4 Polio 3 Hep B 2 MMR 2 Var 2nd Gr 4 DTP/DTaP/DT/Td 4 Polio 3 Hep B 2 MMR 2 Var 3rd Gr 4 DTP/DTaP/DT/Td 4 Polio 3 Hep B 2 MMR 2 Var 4th Gr 4 DTP/DTaP/DT/Td 4 Polio 3 Hep B 2 MMR 2 Var 5th Gr 4 DTP/DTaP/DT/Td 4 Polio 3 Hep B 2 MMR 2 Var 6th Gr 4 DTP/DTaP/DT/Td 1 Tdap 4 Polio 3 Hep B 2 MMR 2 Var 7th Gr 4 DTP/DTaP/DT/Td 1 Tdap 4 Polio 3 Hep B 2 MMR 2 Var 8th Gr 4 DTP/DTaP/DT/Td 1 Tdap 4 Polio 3 Hep B 2 MMR 2 Var 9th Gr 4 DTP/DTaP/DT/Td 1 Tdap 4 Polio 3 Hep B 2 MMR 2 Var 10th Gr 4 DTP/DTaP/DT/Td 1 Tdap 4 Polio 3 Hep B 2 MMR 2 Var 11th Gr 4 DTP/DTaP/DT/Td 1 Tdap 4 Polio 3 Hep B 2 MMR 2 Var 12th Gr 4 DTP/DTaP/DT/Td 1 Tdap 4 Polio 3 Hep B 2 MMR 2 Var

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-04020L (Rev. 06/2017)

STATE OF WISCONSIN Wis. Stat. §§ 252.04 and 120.12 (16)

STUDENT IMMUNIZATION RECORD

INSTRUCTIONS TO PARENT: COMPLETE AND RETURN TO SCHOOL WITHIN 30 DAYS AFTER ADMISSION. State law requires all public and

private school students to present written evidence of immunization against certain diseases within 30 school days of admission. The current age/grade specific requirements are available from schools and local health departments. These requirements can be waived only if a properly signed health, religious or personal conviction waiver is filed with the school. The purpose of this form is to measure compliance with the law and will be used for that reason only. If you have questions regarding immunizations, or how to complete this form contact your child’s school or local health department.

PERSONAL DATA PLEASE PRINT

Step 1 Student’s Name

Birthdate (Mo/Day/Yr)

Gender

School

Grade

School Year

Name of Parent/Guardian/Legal Custodian

Address (Street, City, State, Zip)

Telephone Number

( )

IMMUNIZATION HISTORY

Step 2 List the MONTH, DAY, AND YEAR your child received each of the following immunizations. DO NOT USE A () OR (X) except to answer the question about chickenpox, Tdap, or Td. If you do not have an immunization record for this student at home, contact your doctor or public health department to obtain it.

TYPE OF VACCINE* FIRST DOSE

Mo/Day/Yr SECOND DOSE

Mo/Day/Yr THIRD DOSE

Mo/Day/Yr FOURTH DOSE

Mo/Day/Yr FIFTH DOSE

Mo/Day/Yr

DTaP/DTP/DT/Td (Diphtheria, Tetanus, Pertussis)

Adolescent booster (Check appropriate box)

Tdap Td

Polio

Hepatitis B

MMR (Measles, Mumps, Rubella)

Varicella (Chickenpox) Vaccine Vaccine is required only if your child has not had chickenpox disease. See below:

Has your child had Varicella (chickenpox) disease? Check the

appropriate box and provide the year if known:

YES year (Vaccine not required)

NO or Unsure (Vaccine required)

Has your child had a blood test (titer) that shows immunity (had disease or previous vaccination) to any of the following? (Check all that apply)

Varicella Measles Mumps Rubella Hepatitis B

If YES, provide laboratory report(s)

REQUIREMENTS

Step 3 Refer to the age/grade level requirements for the current school year to determine if this student meets the requirements.

COMPLIANCE DATA

Step 4 STUDENT MEETS ALL REQUIREMENTS Sign at Step 5 and return this form to school.

Or

STUDENT DOES NOT MEET ALL REQUIREMENTS Check the appropriate box below, sign at Step 5, and return this form to school. PLEASE NOTE THAT INCOMPLETLY IMMUNIZED STUDENTS MAY BE EXCLUDED FROM SCHOOL IF AN OUTBREAK OF ONE OF THESE DISEASES OCCURS.

Although my child has NOT received ALL required doses of vaccine, the FIRST DOSE(S) has/have been received. I understand that the

SECOND DOSE(S) must be received by the 90th school day after admission to school this year, and that the THIRD DOSE(S) and FOURTH DOSE(S) if required must be received by the 30th school day next year. I also understand that it is my responsibility to notify the school in writing each time my child receives a dose of required vaccine.

NOTE: Failure to stay on schedule may result in exclusion from school, court action and/or forfeiture penalty.

WAIVERS (List in Step 2 above, the date(s) of any immunizations your child has already received)

For health reasons this student should not receive the following immunizations

______________________________________________________________ ______________________________________________

SIGNATURE - Physician Date Signed

For religious reasons, I have chosen not to vaccinate this student with the following immunizations (check all that apply)

DTaP/DTP/DT/Td Tdap, Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella

For personal conviction reasons, I have chosen not to vaccinate this student with the following immunizations (check all that apply)

DTaP/DTP/DT/Td Tdap Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella

SIGNATURE

Step 5 This form is complete and accurate to the best of my knowledge. Check one: ( I do I do not ) give permission to share my child’s current

immunization records and as they are updated in the future with the Wisconsin Immunization Registry (WIR). I understand that I may revoke this consent at any time by sending written notification to the school district. Following the date of revocation, the school district will provide no new records or updates to the WIR. ___________________________________________________________________ ____________________________________________

SIGNATURE - Parent/Guardian/Legal Custodian or Adult Student Date Signed

State Immunization Requirements Rev. 2020

STATE OF WISCONSIN IMMUNIZATION REQUIREMENTS

2020-2021 SCHOOL YEAR

2-4 yrs 4 DTP/DTaP/DT 3 Polio 3 Hep B 1 MMR 5 1 Var6

KG 4 DTP/DTaP/DT/Td1 4 Polio4 3 Hep B 2 MMR5 2 Var6

1st Gr 4 DTP/DTaP/DT/Td1 4 Polio4 3 Hep B 2 MMR 5 2 Var6

2nd Gr 4 DTP/DTaP/DT/Td1 4 Polio4 3 Hep B 2 MMR 5 2 Var6

3rd Gr 4 DTP/DTaP/DT/Td2 4 Polio4 3 Hep B 2 MMR 5 2 Var6

4th Gr 4 DTP/DTaP/DT/Td2 4 Polio4 3 Hep B 2 MMR 5 2 Var6

5th Gr 4 DTP/DTaP/DT/Td2 4 Polio4 3 Hep B 2 MMR 5 2 Var6

6th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

7th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

8th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

9th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

10th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

11th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

12th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

1. DTP/DTaP/DT vaccine for children entering Kindergarten: Your child must have received onedose after the 4th birthday (either the 3rd, 4th or 5th) to be compliant. (Note: a dose 4 days orless before the 4th birthday is also acceptable).

2. DTP/DTaP/DT/Td vaccine for students entering PreK and grades 1 through 12: Four doses arerequired. However, if your child received the 3rd dose after the 4th birthday, further doses are notrequired. (Note: a dose 4 days or less before the 4th birthday is also acceptable).

3. Tdap means adolescent tetanus, diphtheria and acellular pertussis vaccine. If your child received adose of a tetanus-containing vaccine, such as Td, within 5 years of entering the grade in which Tdapis required, your child is compliant and a dose of Tdap vaccine is not required.

4. Polio vaccine for students entering grades Kindergarten through 12: Four doses are required.However, if your child received the 3rd dose after the 4th birthday, further doses are not required.(Note: a dose 4 days or less before the 4th birthday is also acceptable).

5. The first dose of MMR vaccine must have been received on or after the first birthday. (Note: a dose4 days or less before the 1st birthday is also acceptable).

6. Var means Varicella (chickenpox) vaccine. A history of chickenpox disease is also acceptable.

Rev. 2020

SCHOOL DISTRICT OF LA CROSSE

Physical Examination Form Student’s Name______________________________ Grade______ Date of Birth_________________ Parent/Guardian_____________________________ Address_________________________________ Telephone_____________________________ School_____________________________________

Please check the appropriate box

Is there any defect of

vision Yes No

hearing Yes No

speech Yes No

If yes, describe recommendation for School personnel:

Does student have any health conditions that limits:

Classroom activity? Yes No

Homework? Yes No

Physical education? Yes No

Competitive athletics? Yes No

Does this student have any health condition that may require a special health plan or may result in a school emergency such as:

anaphylaxis? Yes No

asthma? Yes No diabetes? Yes No migraines? Yes No seizures? Yes No Other:__________________________

Does this student receive any routine medication during the school day?

Yes No

Please list.

Please Complete School Medication Form

Does this student exhibit any abnormality of

Growth? Yes No

Nutrition? Yes No

Maturation? Yes No

Height _______ Weight ________

For Kindergarten Students, please complete

and attach immunization card.

*Please check reverse side for special DTP requirement for

Kindergarten students.

Signature of Physician _______________________________________________Date____________ Printed/Typed Name Physician___________________________________Phone:________________

Rev. 2020

STATE OF WISCONSIN

IMMUNIZATION REQUIREMENTS

2020-2021 SCHOOL YEAR 2-4 yrs 4 DTP/DTaP/DT 3 Polio 3 Hep B 1 MMR 5 1 Var6

KG 4 DTP/DTaP/DT/Td1 4 Polio4 3 Hep B 2 MMR5 2 Var6 1st Gr 4 DTP/DTaP/DT/Td1 4 Polio4 3 Hep B 2 MMR 5 2 Var6 2nd Gr 4 DTP/DTaP/DT/Td1 4 Polio4 3 Hep B 2 MMR 5 2 Var6 3rd Gr 4 DTP/DTaP/DT/Td2 4 Polio4 3 Hep B 2 MMR 5 2 Var6 4th Gr 4 DTP/DTaP/DT/Td2 4 Polio4 3 Hep B 2 MMR 5 2 Var6 5th Gr 4 DTP/DTaP/DT/Td2 4 Polio4 3 Hep B 2 MMR 5 2 Var6 6th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6 7th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

8th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6 9th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6 10th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6 11th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6 12th Gr 4 DTP/DTaP/DT/Td2 1 Tdap3 4 Polio4 3 Hep B 2 MMR 5 2 Var6

1. DTP/DTaP/DT vaccine for children entering Kindergarten: Your child must have received one dose after the 4th birthday (either the 3rd, 4th or 5th) to be compliant. (Note: a dose 4 days or less before the 4th birthday is also acceptable).

2. DTP/DTaP/DT/Td vaccine for students entering PreK and grades 1 through 12: Four doses are required. However, if your child received the 3rd dose after the 4th birthday, further doses are not required. (Note: a dose 4 days or less before the 4th birthday is also acceptable).

3. Tdap means adolescent tetanus, diphtheria and acellular pertussis vaccine. If your child received a dose of a tetanus-containing vaccine, such as Td, within 5 years of entering the grade in which Tdap is required, your child is compliant and a dose of Tdap vaccine is not required.

4. Polio vaccine for students entering grades Kindergarten through 12: Four doses are required. However, if your child received the 3rd dose after the 4th birthday, further doses are not required. (Note: a dose 4 days or less before the 4th birthday is also acceptable).

5. The first dose of MMR vaccine must have been received on or after the first birthday. (Note: a dose 4 days or less before the 1st birthday is also acceptable).

6. Var means Varicella (chickenpox) vaccine. A history of chickenpox disease is also acceptable.

State of Wisconsin Department of Regulation and Licensing

KINDERGARTEN EYE HEALTH EXAMINATION REPORT Student’s Name_____________________________________ Birth Date_________________ Sex______________ Parent or Guardian__________________________________________________ Phone_______________________ Address___________________________________________________________ County_____________________ School/Kindergarten________________________________________________ City_________________________ Date entering Kindergarten___________________________________________ The State of Wisconsin encourages parents of Kindergartners to arrange for their child’s eyes to be examined by an optometrist or evaluated by a physician by December 31st of the child’s first year in school. An examination or evaluation should include, at a minimum, the elements listed below. (By checking the box, the examining doctor is indicating that the element checked was performed.) Brief history (general health and eye health) of the child, including family history

General external observation of the child’s eyes and surrounding structures

Ophthalmoscopic examination through an undilated pupil

Gross measurement of peripheral vision

Evaluation of eye coordination and function (alignment and motility)

Visual acuity for each eye (separately)

Findings: As a result of this examination, follow-up care for the child is recommended: � Yes � No

Date of examination:

______________________________________ Doctor/Physician Signature: ______________________________________ Print or stamp: Doctor/Physician Name Address Phone

IMPORTANT NOTICE TO PARENTS

This examination is not required by law. Disclosure of the information noted above is necessary to comply with the statutory purpose as outlined in s. 118.135, Wis. Stats. Disclosure of this information is voluntary and there is no penalty for non-compliance. You are encouraged to provide a copy of this form to the school and keep a copy for your record. Consent of parent or guardian: I agree to release the above information on my child to appropriate school authorities and consent to my child obtaining an eye examination. Signature_________________________________________

Date_____________________________________________

NOTE TO PARENT: If you do not feel that you can afford to pay for an eye examination, please contact the Wisconsin Optometric Association toll free at (877) 435-2020. You may qualify for a free examination.

Wisconsin Optometric Association Parent’s Guide to Good Vision and Healthy Eyes!

Vision Facts

� 80% of all learning during a child’s first 12 years of life is obtained through vision. � Vision disorders are the 4th most common disability in the United States and the most

prevalent handicapping condition in childhood.

� 8 to 12 million school age children are at risk from undetected vision impairments The bottom line is: Your child’s ability to see clearly in school will have an enormous impact on their ability to learn. As parents, you can ensure that your child’s academic performance is maximized from the beginning of their education career by having their eyes tested. Undiagnosed and, therefore, untreated vision problems among our children represent one of the most serious, yet overlooked, health issues facing our nation. Under the “Clear Vision, Bright Future” Initiative, Wisconsin optometrists have partnered with parents, school district administrators, school nurses and other health providers to encourage students to receive the eye health and vision care they need. This Initiative provides the opportunity not only to enhance the academic future of your child, but also to provide a strong foundation for those who may be at-risk for visual learning problems. Parents & Teachers-Please do not assume that a child has healthy eyes and no problems seeing in school. That assumption could risk the child’s future eye health and school achievement. Have their eyes examined. Tips for parents scheduling comprehensive eye exams for their children:

1. Schedule the exam early in the day, at least 3-4 months before school starts 2. Let your child know that there won’t be any shot s involved 3. Make a game of it; practice looking at pictures and making it fun

Wisconsin Law A current Wisconsin law, Statute Chapter 118.135 states: Each school board shall request each pupil entering kindergarten to provide evidence that the pupil has had his or her eyes examined by an optometrist or evaluated by a physician. Financial Assistance for Eye Exams Many children in Wisconsin do not have insurance coverage for eye examinations. Member doctors of the Wisconsin Optometric Association (WOA) provide free eye examinations for children who do not have insurance and who cannot afford such care. Please contact the WOA’s VISION USA Program at (877) 435-2020 to reque st an application form or for more information regarding this special program.

The School District of La Crosse encourages families to have their children’s teeth checked by a

dentist at least once a year. Please return the Kindergarten Dental Slip to your child’s teacher the

FIRST DAY OF SCHOOL.

____________________________________ _____________________________________ Name of Child School

This child has been seen for dental care on ____________________________(date). COMMENTS:____________________________________________________________

______________________________________________________________________

___________________________________________________ __________________________ Signature of Dentist Date Printed Name of Dentist__________________________________

Rev. 2020

SCHOOL DISTRICT OF LA CROSSE

KINDERGARTEN DENTAL SLIP

Kindergarten Immunization Requirements 2020-2021

Kindergarten students are required to have the following immunizations: DOSES NEEDED IMMUNIZATION

4 Diphtheria-Tetanus-Pertussis (DTP) - PLEASE NOTE: one dose (either 3rd, 4th or 5th) must have been received after the 4th birthday

4 Polio - if your child received the third dose of polio after the 4th birthday, further

doses are not required 2 Measles-Mumps-Rubella (MMR) (the first MMR must

have been received on or after the first birthday) 3 Hepatitis B

2 Varicella (Chickenpox) Vaccine is needed only if your child has not had chicken-pox disease. Please provide the year your child had the disease or the month, day and year the vaccine was received.

Please have your child’s immunization dates at the school office by the first day of school. Waivers are available on the Student Immunization Record.

——————————————————————————————————————————————————————————————————————————————————-

PLEASE CUT ON DOTTED LINE AND RETURN COMPLETED TOP PORTION TO YOUR CHILD’S SCHOOL

Elementary School

New Student Health Information Enrollment Form 2020-2021

School District of La Crosse

STUDENT NAME: DATE OF BIRTH:

SCHOOL: GRADE:

Dear Parent/Guardian:

Please complete the Health Information Enrollment Form for your child. Below check any current health condition that may require attention during the school day or at co-curricular activities. My child does NOT have any known health concerns.

ADD/ADHD Will your child need medication at school? Yes No

ALLERGIES (Be specific) My child has an EpiPen? Yes No

Foods Reaction

Bee Sting or Insect Bites Reaction

Medicines Reaction

Environmental/Seasonal Reaction

Other Reaction

ASTHMA Will your child need an inhaler at school? Yes No

CARDIAC (HEART) CONDITION Restrictions Yes* No *Requires physician note

DIABETES Insulin Pump Insulin Injections Glucagon

SEIZURE CONDITION Emergency Medication Yes No Include Type:_________________________

OTHER HEALTH CONDITIONS (Please list)______________________________________________________

MEDICATIONS: Please give medications at home whenever possible. All medication given at school requires a School Medication/Procedure Form available on our website, www.lacrosseschools.org, or at your local health care practitioner’s office. If medication is needed during the school day, the following is necessary.

Prescription Medication (1) A doctor’s signature with written instruction.

(2) Written consent from the parent for the school to give the medication.

(3) Medication is in a properly labeled prescription bottle.

Non-prescription Medication (1) Written consent from the parent with instructions for the school to give the medication.

(2) Medication must be in the original container.

Students may not carry medication at school with the exception of prescription inhalers and epinephrine auto injectors with a doctor’s written permission.

Parents/guardians are requested to please deliver medication to the school office.

My signature gives permission to share this health information with school staff and district transportation providers working with my child. This information will be used, if necessary, for safety at school, on field trips and other school activities.

_________________________________________ _____________________________ ________________ Parent/Guardian Signature Relationship Date