Bow high school
Bow High School * Emergency Information *
Parents/ Guardians ~ Please complete and return it to the school nurse.
Remember to notify the school immediately of changes in phone numbers and address and
notify the school nurse of any health changes; medications, health care providers, illness or medical treatment.
Student’s Name: _____________________________________________________________ Grade: ____________ School Year: ______________ D.O.B. _______________ Age: ________ Address: _______________________________________________________ Tel. _________________ Name of Parent/Legal Guardian with whom student lives and relationship:____________________________________________________________ Parent/Guardian Pager/Cell Phone # ____________________ ____________________Parent/Guardian Email: ________________________ Mother’s Employer: ___________________________ Tel._____________ Father’s Employer: _________________________ Tel. ____________ Student’s Physician: ______________________________ Tel. ____________ Student’s Dentist: _______________________ Tel._____________ Student’s Medical Insurance Co: ________________________________Policy # _________________________ Group # ____________________ Friend or relative who would be willing to assume temporary care of your child during school hours if you cannot be reached:
Name:____________________________________________________________________________ Tel. ______________
Please indicate if the student has any of the following:
Has the student been treated for any of the following in the past year?
Is the student on any daily medication(s)? Yes No
Medication: __________________ Dose _________ Time taken ______
Last Tetanus Immunization
_________________ Type of vaccine
______________ Tdap vaccine is required for students with
MM/DD/YR more than 5 years since their last tetanus immunization
Students needing medication prescription and/or non-prescription during the school day must follow NH laws regarding the
administration of medications in schools. Students may not carry medications except for asthma inhalers and EpiPen (epinephrine)
with proper written approval from a health care provider and parent.
I give permission for the school nurse to administer over the counter medications according to the manufacturer’s instructions to my
child as requested. The following are stocked over the counter medications (their generic equivalent may be substituted): Tylenol,
Advil, Robitussin, Sudafed, Benadryl, Pepto-Bismol, Tums, Immodium AD, Eye Saline, Visine, Anbesol, Neo-synephrine, Isopropyl
Alcohol, Hydrogen peroxide, Antibacterial soap, Aloe Gel, Bacitracin, Calamine Lotion, Caladryl, Burn Gel, Hydrocortisone Lotion,
Bee Sting Swabs Yes
In the event of a medical emergency and I can not be reached, this authorization gives consent for the school to call the physician or
dentist listed and to follow his/her instructions or seek emergency medical assistance as needed. Signature of Parent/Guardian
February 2014 Highlights New to HEED this month We have added 75 new ful reviews and 11 non–English language articles from France, Spain and Germany. Featured Reviews The following reviews are some of the highlights from this month’s issue of HEED: Economic evaluation of poison centers: a systematic review Galvao T F, Silva E N, Silva M T, Bronstein A C, Pereira M G; Int
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