Student’s Name _______________________________ School Year _______________ Grade/Teacher ___________ Family Physician _________________________________________ Physician Phone _________________________ My child can participate in all activities including physical education. Yes ________ No _________ If no, please provide medical documentation from your child’s physician. If necessary, according to Medical Director’s standing orders, my child may have:
Please Note: Students requesting frequent administration of above medications require an Authorization for the
Administration of Medicine order filled out by a physician/dentist/orthodontist.
Please notify the school nurse if your child has any of the following medical conditions:
If you answer “yes” to any of the above, please explain ____________________________________________________ _____________________________________________________________________________________________ Asthma __________ Uses inhaler/nebulizer _________________ Needs Medication at School (Yes/No) ___________ Food Allergy ___________________________________________ Requires Epipen/Benadryl ____________________ Bee Sting Allergy _______________________________________ Requires Epipen/Benadryl ____________________ Drug Allergy ___________________________________________________________________________________ Any other medical conditions _______________________________________________________________________ List any medications taken at home or school on a daily basis: _______________________________________________ List dates and types of any communicable disease your child has had during the past year (ex: Rheumatic fever, Poliomyelitis, Scarlet Fever, Pneumonia, Mumps, Measles, Chicken Pox, German Measles) ______________________________________ ______________________________________________________________________________________________ Please list any other problems that you feel the school nurse should be aware of __________________________________ ______________________________________________________________________________________________ Would you like the above information shared with the bus company? Would you like the above information shared with the school staff? I give permission for the school nurse to contact my child’s physician as needed to obtain medical information.
When your child is ABSENT, please call the school anytime and leave a message, including your child’s name, teacher and
problem (sick, injured, family emergency, etc.). Otherwise, you will be called at home or at work.

SCOLIOSIS SCREENING: Students in 5th – 9th grade are required to have a postural screening done. The screenings will be
performed in the spring. If you DO NOT want your child to participate in this screening at school, please check the reason
______ His/Her health care provider will conduct the screening at their physical this school year. ______ He/She is under the care of a doctor for scoliosis. SWISH PROGRAM: As part of the Dental Health Program here at Lisbon Central School, a weekly “Swish” program is offered
to all students from Kindergarten through Grade 8.
My child may participate in the weekly SWISH fluoride program.
I, the undersigned, do hereby authorize officials of Lisbon School District to contact directly the persons named as emergency contacts and do authorize the named physicians to render such treatment as may be deemed necessary in an emergency, for the health of said child. In the event that physicians, emergency contacts, or parents cannot be reached, the school officials are hereby authorized to take whatever action is deemed necessary in their judgement, for the health of the aforesaid child. I will not hold the school district financially responsible for the emergency care and/or transportation for said child. Signature of Parent/Guardian: ________________________________________



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Copyright © Arnold Mann 2008 Member Australian Academy of Forensic Sciences Director The Surgical Unit, Canberra Hospitals, ACT Tutor in Clinical Surgery, University of Melbourne. International Visiting Professor of Surgery 1978 Copyright © Arnold Mann 2008 HOW TO USE THIS BOOK IF YOU ARE NOT A MEDICAL PRACTITIONER When you meet an unfamiliar word, do not skip

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