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
No Comments/Exceptions: __________________________________________
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: ___________________________________Date: ________________

Source: http://www.bow.k12.nh.us/bhs/pdf/SummerPacket2011/EMERGENCYSHEET2011.pdf