SUPERINTENDENT

Nikolaos C. Koutsogiannis 350 East Clinton Street

Clayton, NJ 08312 856-881-8700 school

856-863-8196 fax

HERMA SIMMONS

(PK – 5th) 300 West Chestnut Street

Clayton, NJ 08312 856-881-8704 school

856-307-0924 fax Scott Uribe, Principal

Alicia Fragoso, Assistant Principal

CLAYTON MIDDLE

(6th – 8th) 55-B Pop Kramer Blvd

Clayton, NJ 08312 856-881-8701 school

856-881-8623 fax Marvin Tucker, Principal

Matthew Slater, Assistant Principal

CLAYTON HIGH

(9th – 12th) 55-A Pop Kramer Blvd

Clayton, NJ 08312 856-881-8701 school

856-863-0808 fax Joseph Visalli, Principal

Daniel Antonelli, Assistant Principal and Athletic Director

www.claytonps.org

PRE-SCHOOL 3-YEAR OLD REGISTRATION PACKET

Welcome to the Clayton Public School District!!! Your child must be three (3) years of age on or before October 1, 2020 to enroll in our tuition-free, full-day PK3 year old program.

BREAKFAST and TRANSPORTATION is provided to all preschool students at no cost to parents.

REGISTRATION PROCESS

1. Get a registration packet. Download and print from our website: www.claytonps.org 2. Make a registration appointment. Packets are submitted BY APPOINTMENT ONLY. Please go to https://claytonps.org/registration-booking/ to schedule your appointment.

** ONLY ONE PERSON WILL BE ALLOWED TO ENTER THE BUILDING FOR APPOINTMENT ** ** MASKS MUST BE WORN WHEN ENTERING BUILDING **

3. Bring completed registration packet and ALL of the following documentation to appointment. Incomplete packets and/or missing documents will require your appointment to be rescheduled.

A. PROOF OF RESIDENCY – must display parent or guardian name 1. Lease/rental agreement OR mortgage/deed/settlement OR recent property tax bill

and 2. Any utility bill issued within the last 30 days OR mail received from any federal, state or local government agency in the past six months

B. PROOF OF CHILD’S AGE, IDENTITY, GUARDIANSHIP and CUSTODY: Birth certificate, passport, hospital birth record, adoption record, baptismal certificate, or legal custody papers (if applicable).

C. HEALTH DOCUMENTS REGARDING STUDENT: Immunization record with dates for each immunization AND physical examination signed by child’s Health Care Provider and dated within one year of registration. Medical or religious exemptions must be submitted in writing. ** If your child has allergies, seizures or asthma – please ask for additional health forms during registration **

D. ACADEMIC RECORDS FOR STUDENTS TRANSFERRING FROM ANOTHER SCHOOL: 1. State Identification Number (SID) 2. Transfer card with name, address and telephone number of previous school 3. Current schedule and grades as of withdrawal date 4. Last issued report card and last issued standardized test results 5. Current IEP for students receiving services through the Child Study Team E. IDENTIFICATION: Any form of identification for parent or guardian STILL HAVE QUESTIONS: Contact Ms. Downes, 856-881-8700 EXT 3051, rdownes@claytonps.org

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CLAYTON PUBLIC SCHOOL DISTRICT 2020-2021 Household Information Survey

The purpose of this survey is to obtain information that can be used by the District to apply for various grants and appropriate grant funding correctly. The information obtained is confidential and will only be used as stated. This form is NOT part of the student’s academic file.

HOUSEHOLD INFORMATION

Is parent or guardian an active member of the military? Does any member of your household receive NJ SNAP? YES NO YES NO Does any member of your household receive TANF? Does any member of your household receive SSI? YES NO YES NO

STUDENT #1: _______________________________________________________________________________ GRADE: __________________

Choose ETHNICITY: Hispanic or Latino Not Hispanic or Latino Choose RACE(S): Asian American Indian or Alaska Native Black or African-American White Native Hawaiian or Pacific Islander Please check the appropriate box to answer the following question for Student#1: After school my child: participates in a school sponsored activity attends a Child Care Program goes home

STUDENT #2: _______________________________________________________________________________ GRADE: __________________

Choose ETHNICITY: Hispanic or Latino Not Hispanic or Latino Choose RACE(S): Asian American Indian or Alaska Native Black or African-American White Native Hawaiian or Pacific Islander Please check the appropriate box to answer the following question for Student#2: After school my child: participates in a school sponsored activity attends a Child Care Program goes home

STUDENT #3: _______________________________________________________________________________ GRADE: __________________

Choose ETHNICITY: Hispanic or Latino Not Hispanic or Latino Choose RACE(S): Asian American Indian or Alaska Native Black or African-American White Native Hawaiian or Pacific Islander Please check the appropriate box to answer the following question for Student#3: After school my child: participates in a school sponsored activity attends a Child Care Program goes home

STUDENT #4: _______________________________________________________________________________ GRADE: __________________

Choose ETHNICITY: Hispanic or Latino Not Hispanic or Latino Choose RACE(S): Asian American Indian or Alaska Native Black or African-American White Native Hawaiian or Pacific Islander Please check the appropriate box to answer the following question for Student#4: After school my child: participates in a school sponsored activity attends a Child Care Program goes home

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Clayton Public School District Nikolaos C. Koutsogiannis, Superintendent of Schools

Herma Simmons Elementary School

Scott Uribe, Principal Alicia Fragoso, Assistant Principal

300 West Chestnut Street

Clayton, NJ 08312 (856) 881-8704, school

(856) 307-0924, fax

RECORDS RELEASE FORM

Student Name: _________________________________________________________ DOB: _______________________________ Grade Level: ______________________ Does student have: _____ IEP _____ 504 _____ IR&S/PAC Previous School Name: ___________________________________________________ Previous School Address: _________________________________________________ Previous School City/State/Zip: _____________________________________________ Previous School Phone: __________________________________________________ Previous School Fax: ____________________________________________________ I am the parent/guardian of the above-named student. I give his/her previous school permission to release ACADEMIC RECORDS, HEALTH RECORDS, TEST SCORES, DISCIPLINE RECORDS, ATTENDANCE RECORDS and CONFIDENTIAL RECORDS (i.e. PSYCHOLOGICAL REPORTS, LEARNING DISABILITY EVALUATIONS, SOCIAL HISTORY, INDIVIDUALIZED EDUCATION PLAN, etc.) to the Clayton Public School District upon request. Parent/Guardian: _______________________________________________________ (print name)

Date: _____________ Signature: ________________________________________

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CLAYTON PUBLIC SCHOOL DISTRICT

Student Registration Packet for PK3

STUDENT#:_____________ STUDENT GENDER: Female Male New Student Returning Student

NAME _______________________________________________________________________________________________________________ Last First Middle

ADDRESS ____________________________________________________________________________________________________________

PRIMARY PHONE NUMBER _______________________________ If this is a cell phone: Is it okay to send text messages? YES NO

DOB _________________________ CITY and STATE OF BIRTH: ____________________________________________________ COUNTRY OF BIRTH: UNITED STATES OTHER:_____________________________ AGE as of OCTOBER 1st: ___________ ETHNICITY: Hispanic or Latino Not Hispanic or Latino

RACE: Asian American Indian or Alaska Native Black or African-American White Native Hawaiian or Pacific Islander Was the student receiving any services through the Child Study Team in his/her previous school? YES NO Did the student have an active 504 Plan in his/her previous school? YES NO Did the student ever attend a day care or head-start program? YES NO Program Name/Location: _______________________________

PARENT or GUARDIAN INFORMATION #1 Does student live with you? YES NO

RELATIONSHIP TO STUDENT: Mother Father Grandmother Grandfather Aunt Uncle Other: _____________________

NAME _______________________________________________________________________________________________________________ Last First Middle

ADDRESS ____________________________________________________________________________________________________________

HOME PHONE _______________________________ CELL PHONE _____________________________ Text messages okay: YES NO

E-MAIL: ___________________________________ If not parent, do you have a court order or power of attorney for guardianship? YES NO

PARENT or GUARDIAN INFORMATION #2 Does student live with you? YES NO

RELATIONSHIP TO STUDENT: Mother Father Grandmother Grandfather Aunt Uncle Other: _____________________

NAME _______________________________________________________________________________________________________________ Last First Middle

ADDRESS ____________________________________________________________________________________________________________

HOME PHONE _______________________________ CELL PHONE _____________________________ Text messages okay: YES NO

E-MAIL: ___________________________________ If not parent, do you have a court order or power of attorney for guardianship? YES NO

SIBLING INFORMATION

NAME ___________________________________ DOB ______________GRADE_____ SCHOOL___________________

NAME ___________________________________ DOB ______________GRADE_____ SCHOOL___________________

NAME ___________________________________ DOB ______________GRADE_____ SCHOOL___________________

NAME ___________________________________ DOB ______________GRADE_____ SCHOOL___________________

EMERGENCY CONTACT INFORMATION

NAME RELATIONSHIP TO STUDENT CONTACT NUMBER

___________________________________________ _______________________________ ________________________________ H W C

___________________________________________ _______________________________ ________________________________ H W C

___________________________________________ _______________________________ ________________________________ H W C

___________________________________________ _______________________________ ________________________________ H W C

MEDICAL INFORMATION

DOCTOR’S NAME ___________________________________________________________________________________________________

ADDRESS __________________________________________________________________________________________________________

PHONE NUMBER ________________________________ Hospital Choice: JFK Elmer Underwood Other: ________________

Does student have any chronic or acute medical conditions? YES NO If YES, please explain: ___________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________

CLAYTON PUBLIC SCHOOL DISTRICT Home Language Survey Form

This survey is the first of three steps to identify whether or not a student is eligible to be an English language learner (ELL). Start with “Question 1” and continue until the HLS is complete. Write or circle the answer for each question and follow the directions.

Student Information Student Name: ____________________________________ Student Birth Date: _______________ Street Address: _____________________________________________________________________ City: _________________________ State: __________ Zip Code: __________________

Phone Number: ( __ __ __ ) __ __ __ - __ __ __ __

Survey Questions 1. What was the first language used by the student? ____________________________________ 2. At home, does the student hear or use a language other than English more than half of the

time? _____Yes _____No 3. Does the student understand a language other than English? _____Yes _____No 4. When interacting with his/her parents or guardians, does the student use a language other than English more than half of the time? _____Yes _____No 5. When interacting with caregivers other than their parents or guardians, does the student use a language other than English more than half of the time? _____Yes _____No 6. Has the student recently moved from another school district/charter school where he/she was identified as an English language learner? _____Yes _____No 7. List home languages spoken: ________________________________ ________________________________ ________________________________ ________________________________

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CLAYTON PUBLIC SCHOOL DISTRICT Enrollment Residency Questionnaire

Student’s Name: __________________________________________________________________________________

In accordance with New Jersey State law (NJSA 18A:38-1 and 18A:7B-12), it is necessary to determine the residence of students entering the school district. Please indicate which situation best describes the student’s CURRENT residence: ______ Student lives with parent/guardian in their own home or apartment.

• Complete Affidavit of Residency for Permanent Resident

OR

______ DCP&P placed student in ___ Foster Home ___ Treatment Home ___Group Home Name of Case Worker: _________________________________________________________ Office Location: _______________________________________________________________ Contact Number: ______________________________________________________________

• Complete Affidavit of Residency for Permanent Resident • Provide Resource Parent Identification Letter AND Education Stability Letter from DCP&P

OR

______ Student is temporarily living with family member or friend WITH parent or legal guardian due to loss of housing, economic hardship, or similar reason

• Complete Affidavit of Residency for Temporarily Displaced Student (McKinney Vento Homeless Assistance Act)

OR

______ Student is temporarily living with family member or friend WITHOUT parent or legal guardian due to economic hardship, family conflict or other reason

• Complete Affidavit of Residency and Support for an Unaccompanied Youth __________________________________________________________________________ ______________________________ Signature of Parent, Legal Guardian or Resident Date

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CLAYTON PUBLIC SCHOOL DISTRICT Affidavit of Residency for Permanent Resident

Student Name: ____________________________________________________ Date: ___________________________ I, ______________________________________________________________ swear under oath that the following is true: (Name of Parent or Legal Guardian)

1. On or about _____________________ I moved into the Borough of Clayton, in the State of New Jersey. (Date)

2. My street address is: __________________________________________________________________ and I will be residing here on a permanent basis with the above-mentioned student.

3. I am the __mother __father __legal guardian of the Student listed above and he/she lives with me in Clayton at the address listed in Statement 2. 4. In order to document the validity of my residency, I am providing the Clayton Board of Education with a copy of my property tax bill, mortgage bill, deed, settlement papers, rental agreement or lease agreement AND any utility bill issued within the last 30 days OR mail received from any federal, state or local government agency in the past six months

5. My previous address was: _______________________________________________________________ _____________________________________________________________________________________

and I moved from this address because _____________________________________________________

_____________________________________________________________________________________

6. The Student listed above __was __was not enrolled in school prior to moving to Clayton. Name or previous school: _______________________________________________________________ Address of previous school: ______________________________________________________________ ______________________________________________________________ PARENT or LEGAL GUARDIAN: _______________________________________________________________________ (Print name)

PARENT or LEGAL GUARDIAN: _______________________________________________________________________ (Signature)

Sworn to and subscribed before me this _____________ day of _________________________________________, 202__ ______________________________________________________________________________________, Notary Public

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Simmons Emergency Alert Form

In the event your child becomes ill or has an accident at school, the school nurse may need to reach you or a person you designate. It is very important that we know how to reach you or your designee. Please complete this form and return it to school as soon as possible.

Student’s Name: __________________________________________________ Teacher: _________________________ Student’s Address: ___________________________________________________________________________________ Mailing Address (if different): ___________________________________ Home#: ________________________________ Mother’s Name: ________________________________________________ Work#: ______________________________ Mother’s Address (if different): __________________________________________________________________________ Home#: _____________________Cell#: _______________________ E-mail: ____________________________________ Father’s Name: ________________________________________________ Work#: ______________________________ Father’s Address (if different): __________________________________________________________________________ Home#: _____________________Cell#: _______________________ E-mail: ____________________________________

LIST THE NAMES OF THREE (3) LOCAL FRIENDS OR RELATIVES TO CALL IF YOU ARE NOT AVAILABLE (Student will only be released to those listed on this sheet)

NAME: _____________________________________________________ HOME#: ______________________________ ADDRESS: ________________________________________________________________________________________ RELATIONSHIP: _____________________ WORK#: ________________________ CELL#: _______________________ NAME: _____________________________________________________ HOME#: ______________________________ ADDRESS: ________________________________________________________________________________________ RELATIONSHIP: _____________________ WORK#: ________________________ CELL#: _______________________ NAME: _____________________________________________________ HOME#: ______________________________ ADDRESS: ________________________________________________________________________________________ RELATIONSHIP: _____________________ WORK#: ________________________ CELL#: _______________________

I DO DO NOT give consent for the persons listed above to sign my children out of school in cases of emergency. __________________________________________________________________________ _____________________________ Signature of Parent, Legal Guardian or Resident Date

Simmons Emergency Alert Form PART 2

THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND RETURNED TO SCHOOL AS SOON AS POSSIBLE. INSUFFICIENT INFORMATION OR INCOMPLETE FORMS WILL BE RETURNED. FAILURE TO COMPLETE AND RETURN THIS FORM WILL RENDER NO EMERGENCY CONTACTS FOR YOUR CHILD DURING AN EMERGENCY SCHOOL CLOSING.

This information will be used in the event of an emergency closing during the school day. Volunteer parents will call the numbers you provide to inform you of the early dismissal or other emergency. PLEASE CHECK ONE OF THE FOLLOWING: ______ Student will go to Trinity Learning Center or Golden Gate. I understand I will not get a telephone call. ______ Student takes Simmons School bus ______ Student walks home ______ Student will get picked up by: *NAME: __________________________________________________________ HOME#: _______________________ WORK#: ______________________ CELL#: _______________________ * This person should either be a parent or designated person you have made arrangements with regarding your child. The phone numbers provided cannot be a pager because neither the school nor the volunteer can be reached for incoming calls during an emergency. If you list yourself, please provide a phone number where you can be reached during the day. If you list someone else, you will not receive a call – we will only call the person listed. It is very important that you review with your child where he/she should go in the event of an emergency closing. PLEASE LIST ALL OF STUDENT’S SIBLINGS WHO ARE ENROLLED IN THE CLAYTON PUBLIC SCHOOL DISTRICT: NAME: _______________________________________ GRADE: ________ TEACHER: __________________________ NAME: _______________________________________ GRADE: ________ TEACHER: __________________________ NAME: _______________________________________ GRADE: ________ TEACHER: __________________________ NAME: _______________________________________ GRADE: ________ TEACHER: __________________________ Do you wish to receive a phone call in case of an emergency that requires an early dismissal? ____ YES contact me at the following number in case of an emergency early dismissal: _____________________ ____ NO (if you check “NO” you will NOT receive a call) __________________________________________________________________________ ______________________________ Signature of Parent, Legal Guardian or Resident Date

STUDENT NAME: ____________________________________ GRADE: ___________ 2020-2021 Page 1 of 2

DATE OF BIRTH: ____________________________________ HOMEROOM TEACHER: ___________________________

ELEMENTARY SCHOOL Required Annual Health History Update

Both sides of this form are to be completed by the parent/guardian:

Student Address ____________________________________________________________________________________

Parent/Guardian Name __________________________ Home Phone________________ Work Phone________________

Parent/Guardian Name __________________________ Home Phone________________ Work Phone________________

Emergency Contacts: Please list three persons we may call if you cannot be reached in the event of an emergency or if your child needs to be picked up from school.

1. Name______________________________ Relationship__________________ Daytime Phone__________________

2. Name______________________________ Relationship__________________ Daytime Phone__________________

Medical Update: Please check conditions that are either new or still applicable to your child:

_____*Asthma and/or wheezing My child may require an asthma inhaler or nebulizer treatment during the school day. Circle: Yes or No *Asthma medications, including nebulizers or inhalers require an Asthma Action Plan to be completed by your physician. A new one is required each school year. This form is available on the district website under district information: school nurses/health office.

_____*Food Allergies _____*Environmental Allergies My child’s specific allergies are:_________________________________________________________________________ My child’s food and/or environmental allergy requires an Epi Pen or Epi Pen Jr. Circle: Yes or No *Students with severe allergies requiring Epi Pens require an Allergy Action Plan to be completed by your physician and signed by the parent/guardian. A new one is required each school year. This form is available on the district website under district information: school nurses/health office.

______*Seizures My child’s last known seizure was on ____________________________________________________________________ ______If your child has Emergency Seizure medications, please list: ___________________________________________ *Students with a history of seizures require a Seizure Action plan to be completed by your physician and signed by the parent/guardian. A new one is required each school year. This form is available on the district website under district information: school nurses/health office.

______*Diabetes

*Students with diabetes require a Diabetes Action Plan to be completed by your physician. A new one is required each school year. This form is available on the district website under district information: school nurses/health office.

______*ADHD, ADD, ODD, OCD The name of my child’s medication is: _____________________________________ Dose _____________mg ______My child requires this medication to be given at school. Circle: Yes or No *Students requiring any type of medication at school must have a Medication Consent Form completed by your physician and signed by the parent/guardian. A new one is required each year. This form is available on the district website under district information: school nurses/health office.

This form is to be completed AND signed by the parent/guardian annually: Page 2 of 2

Insurance Information: My student has health insurance coverage. YES or NO If yes, please provide name of student’s Health Insurance Company: ___________________________________________

Physician Name______________________________________ Physician Phone_________________________________

If no, NJ FAMILY CARE provides low-cost or free health insurance for uninsured children in certain low-income families. For more information call (800) 701-0710 or visit www.njfamilycare.org to apply – OR –

Physical exams may be obtained locally at: Complete Care Medical Professionals Collegetown Shopping Center 715 Delsea Drive Glassboro, NJ 08028 (856) 863-5720

Immunizations or mantoux tuberculin testing for Gloucester County residents may be obtained at: Gloucester County Health Department 204 E. Holly Ave. Sewell, NJ 08080 (856) 218-4101 _____I give you my permission to release my name and address to the NJ Family Care Program to contact me about health insurance.

Other Pertinent Medical Information:

My child has now or has a history of the following health conditions:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

My child takes the following medications at home (This information is very important in case of a medical emergency):

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

The information on this form is correct, and I give my permission to the school nurse to share pertinent health information regarding my child with essential school personnel, emergency contacts, and my child’s healthcare provider, if needed. I acknowledge that the school and school nurses shall incur no liability because of any condition arising from decisions made on behalf of my child and in the best interest of my child’s health and welfare. I indemnify and hold harmless the school and its employees or agents against claims arising from the decisions made on behalf of my child and in the best interest of my child’s health and welfare.

Healthy Regards, Michele Avallone, RN, BSN, CSN-NJ (ES) mavallone@claytonps.org Julie Kosylo, RN, BSN, CSN-NJ (ES) jkosylo@claytonps.org ____________________________________ _________________________________________ ____________________ Signature of Parent/Guardian Printed Parent/Guardian Name Date

Feel free to email your school nurses at any time. We are dedicated to the health and safety of your child.

To Be Completed by the Health Care Provider

History and Physical Examination

Last Name: ___________________________________ First Name: ____________________________________

Date of Birth: __________________________________ Gender: Male___________ Female _____________

Medical History

Prenatal problems: ___________________________________________________________________________________________

Disease History (Please indicate dates)

Allergies________________________ Asthma_________________________ Otis Media_________________________

Drug Sensitivities_________________ Asthma Action Plan: ___yes ____no Rheumatic Fever____________________

Lyme Disease____________________ Convulsive Disorder_______________ Strep Infections_____________________

Hepatitis________________________ Diabetes________________________ Mononucleosis______________________

Neuromuscular Disorder____________ Heart Disease____________________ Heart Murmur_______________________

Heart Defect_____________________ Cancer__________________________ Seizures___________________________

Chicken Pox_____________________ Congenital Anomalies______________ Pneumonia_________________________

Other/Surgical Procedures (list dates):_____________________________________________________________________________

Is this child receiving any medications? ___________________________________________________________________________

Immunization History (Please indicate the month, day and year or attach official immunization form)

Vaccine Type 1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose DPT, DT or Dtap OPV or IPV MMR HIB Hepatitis B Varicella Hepatitis A Pneumococcal* Influenza*

*Required for Preschool Students only

Country of Birth_____________________ Transferring into NJ from _______________________ If from country with high incidence of TB please test as per NJ Dept. of Health Tuberculosis Program guidelines.

Tuberculosis testing for NJ Department of Education TB Screening as follows:

Mantoux testing Date_______________ Results____________________________________________

IGRA Bloodwork Date_______________ Results____________________________________________

Chest X-Ray: Date_______________ Results____________________________________________

Please complete both sides of form Page 1 of 2

Student’s Name: ______________________________________________________________________ Page 2 of 2

Physical Examination

Height______________________________ Weight________________________ Blood Pressure_______________________

Eyes ______________________________________ Ears _________________________________________________

Nose ______________________________________ Mouth and Teeth _______________________________________

Throat _____________________________________ Tonsils/Adenoids _______________________________________

Lymph glands _______________________________ Skin _________________________________________________

Heart ______________________________________________________________________________________________________

Murmur? ______________________________ Functional _______________________ Pathologic ________________________

Any Restrictions? ____________________________________________________________________________________________

Lungs _____________________________________________________________________________________________________

Musculoskeletal ______________________________ Scoliosis ______________________________________________

Abdomen ___________________________________ GI/GU ________________________________________________

Hernia _____________________________________ Nervous System ________________________________________

Speech ____________________________________________________________________________________________________

Growth and Development ______________________________________________________________________________________

Previous serious injuries, illness or deformities _____________________________________________________________________

Does this child have any physical needs or restrictions that would prevent or limit participation in school activities, including gym and

sports activities? ________No ___________Yes

Please Describe _____________________________________________________________________________________________

__________________________________________________________________________________________________________

Hearing Results

Db Level ____________ For each frequency, please indicate: P=Pass F=Fail

500Hz 1000Hz 2000Hz 3000Hz 4000Hz

Right:

Left:

Conclusion: (Please circle one): Pass Fail

Referral made for further testing: (Please circle one): Yes______ No_____

Comments: _________________________________________________________________________________________________

__________________________________________________________________________________________________________

Vision Results

Right: 20 / _____ Left: 20 / _____ Both: 20 / _____ If vision screening over 20/30, was referral made: Yes_____ No______

Physician’s Signature_______________________________________________ Date of Exam ___________________

Office Stamp:

STUDENT NAME: _________________________________________________ GRADE: ___________ 2020-2021

DATE OF BIRTH: ____________________________________ HOMEROOM TEACHER: ___________________________

Medication Consent Form (Return to the School Nurse)

Whenever possible the parents are advised to give medication at home and on a schedule other than during school hours. IF IT IS NECESSARY that a medication be given during school hours these instructions must be followed:

1. Medication must be brought into school by an adult. 2. Medication to be given must be brought to school in its original container with the appropriate label intact (no Ziploc bags). 3. Permission to dispense medication must be completed by prescribing physician/nurse practitioner/dentist, etc. 4. Permission to administer medication must be completed by the parent/guardian. 5. This form is applicable for the current school year and a new form must be submitted each year.

To be completed by the physician/nurse practitioner, dentist, etc: (Permission to Dispense) In order to provide an appropriate educational program the following medication(s) must be provided to this student during the school day.

Diagnosis/Condition ___________________________________________________________________________________________

Medication Route Dose Time(s)

During a field trip: In the event that the school nurse or a substitute cannot be sent on the trip, a student may not receive medication while on the field trip. If advisable, please give the school nurse directions on how to alter the student’s medication regime for a field trip. __________The nurse may skip the medication during the day in the case of a field trip. __________The medication may be given on an alternate schedule for the day of the field trip. The altered schedule is:_____________________________________________________________________________. __________The student may self-administer medication under adult supervision. _______________________________________ ________________________ Signature of Practitioner Date _______________________________________ ________________________ Printed Name of Practitioner Office Phone Number To be completed by the parent/guardian: (Permission to Administer) The School Nurse has my permission to administer the above medication(s) to my child as prescribed and noted above during school and on field trips. I understand that all medications(s) must be in the original container with the appropriate label intact, and must be brought to the school by an adult. The School Nurse has my permission to contact my child’s health care provider identified above for information/records as needed to care for my child. _____________________________________ _______________________________________ ____________________ Signature of Parent/Guardian Printed Parent/Guardian Name Date

Office Stamp: