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Health Services Forms

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Emergency Information Update Form:  Each year, parents of enrolled students are given a copy of their child's Student Health and Emergency form to update. An updated form is extremely important to have on file if your child has a health emergency during the school day. Also, the school nurse uses the updated information to address any health needs that may impact your child's success in school.

If your contact information (phone numbers, address, and emergency contacts) changes during the school year, please notify the school's main office of the changes right away.

 

Medication Administration Form (Prescription):  Prescription medication will be given at school only when failure to take the medication could jeopardize a student’s health.  This form must be completed and signed by the parent/guardian and a Licensed Healthcare Provider.  The medication must be brought to school by an adult in the prescription bottle with the pharmacy label intact.  

 

Medication Administration Form (Over-the-Counter):  This form is required for the school district to administer non-prescription medication.  Medication must be kept in the original bottle with the manufacturer’s label intact and have a current expiration date.  Medication will be administered in accordance with the manufacturer’s instructions.  Any request for dosage exceeding the recommendations of the manufacturer’s label will require a signed authorization from a physician/licensed healthcare provider.  

 

Authorization to Self-Administer/Self-Carry Non-Prescription Pain Relievers (MS/HS Students Only):  According to MS Chapter 121A.222 and Yellow Medicine East District Policy 516, a secondary student may possess and use non-prescription pain relief in a manner consistent with the labeling if the district has written parental or legal guardian authorization. However, this law does not apply to the possession or use of any drug or product containing ephedrine or pseudoephedrine as its sole active ingredient or as one of its active ingredients.  Policy 516 specifically allows this privilege to students in grades 6-12.

If you wish to allow your child to carry and self-administer non-prescription pain relieving/fever reducing medications (i.e. acetaminophen, ibuprofen, naproxen, aspirin), this form must be completed and signed by the student and the parent/guardian.  The medication must be kept in the original container and must be used in a manner consistent with the manufacturer’s instructions.  Students are not permitted at any time to share medication with others.  The school district may revoke a student’s privilege to possess and use non-prescription pain relievers if the school district determines that the student is abusing the privilege.

 

Medical Release of Information:  Form that may need to be completed and signed by the parent/guardian to facilitate communication and exchange of information with your child's hat may be necessary for accurately helping to manage and maintain a student healthy and safe during the school day.