To be completed by the licensed health care prescriber:

Transcription

1 Bethel Baptist Christian Academy Phone: 716/ Hunt Road, Jamestown, NY Fax: 716/ PARENT AND PRESCRIBER S AUTHORIZATION FOR ADMINISTRATION OF MEDICATION IN SCHOOL Child s Name D.O.B. Grade To be completed by the parent or guardian: I request that my child, listed above (check all that apply): Receive prescription and/or over-the-counter medication as prescribed by our licensed health care provider. Be assisted in taking his/her prescribed inhaler described below during the school day by authorized personnel (inhaler is kept in health office or other approved location). Be permitted to carry and/or administer his/her own prescribed inhaler to himself/herself as authorized by me and my child s Health Care Provider below. Prescription medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand the school nurse, or other assigned person will administer medications. See Medication Policy in the BBCA Parent/Student Handbook for further guidelines. I agree that the information listed on this page may be shared with appropriate faculty/staff or health care providers if deemed advisable by the person in charge. Signature (Parent or Guardian) Date To be completed by the licensed health care prescriber: I request that my patient, as listed above, receive the following PRESCRIPTION MEDICATION: Diagnosis: Medication Dosage Frequency Route Time Duration Possible side effects and adverse reactions (if any): Student is designated Self-Directed (carries and/or administers own asthma medication): Yes No Other Information I request that my above listed patient may receive the following OVER-THE-COUNTER MEDICATIONS during school hours (and extra-curricular activities) to be given as directed on label following age specific guidelines. Please circle all medications that BBCA may administer. Acetaminophen (pain reliever) Tussin DM (cough syrup) Pepto Bismol (stomach relief) Ibuprofen (pain reliever) Cepacol (throat lozenges) Tums (antiacid) Benadryl (antihistamine) Mentolyptus (cough drops) Neosporin (antibiotic cream) Sudafed PE (decongestant) Vit C Defense (supplement drops) Hydrocortisone (anti itch cream) Refresh Plus (lubricant eye drops) Name of licensed prescriber and Title (please print): Prescriber s Signature Date 2/ of 1 Parent/Prescriber Authorization Form

2 Bethel Baptist Christian Academy phone: 716/ Hunt Road fax: 716/ Jamestown NY Health Form and Authorization for Medical Treatment Form Student s Name Date of Birth Grade Part 1 NEW STUDENTS ONLY 1. Immunizations: All new students are required to provide official immunizations to BBCA within the first 30 days of school. Official records would be either immunization records from a previous school or a copy from a doctor s office/clinic. 2. All new students must provide documentation of a current physical within the past 12 months. Part 2 ALL STUDENTS 1. Please note any information that would be helpful to an attending physician in a medical emergency. My child wears contacts Yes No My child has the following allergies: My child has this special condition My child takes the following prescription drugs Other relevant and appropriate information Date of last tetanus shot (month/year) / 2. Family s Physician s Name Phone Hospitalization Coverage: Insurance Company or Govt. Program I.D. or Contract # 3. Permission is granted for the student named above to travel with BBCA athletic teams, or any school sponsored function, to and from games, or functions, by bus (or car if necessary). 4. In case of emergency we do do not give permission for medical treatment at the nearest medical facility if deemed advisable by the person in charge. This permission is also granted for home games when we cannot be contacted. Emergency Phone Numbers Home ( ) - Father s Work ( ) - / cell # - Mother s Work ( ) - / cell # - Other Emergency Contact ( ) - Name & Relationship to student Other Emergency Contact ( ) - Name & Relationship to student 5. We will not hold BBCA responsible for accident/injury liability, either during school hours or during extra-curricular activities including athletic contests, class trips, and class socials. 6. We agree that the above information may be shared with appropriate faculty/staff or health care providers if deemed advisable by the person in charge. Signatures of both parents (or guardians) are required. Mother Date Father Date 2/2011 Health Form & Authorization for Medical Treatment 1 of 1

3 Bethel Baptist Christian Academy phone: 716/ Hunt Road fax: 716/ Jamestown, NY HEALTH HISTORY FORM Must be completed annually for ALL Students. Page 1 to be completed by Parents/Guardians. Name Birth Date Grade Family Dentist Date of last visit (NYS requires a copy of dental exam to be on file for students entering grades K, 2, 4, 7, & 10 and ALL NEW STUDENTS). Family Physician Date of last visit (NYS requires a copy of physical exam to be on file for students entering grades K, 2, 4, 7, & 10, ALL NEW STUDENTS and ALL STUDENTS PLAYING SPORTS). History Do you have any of the following? Include date, if appropriate. If more explanation is needed, use lines below. Allergies Nosebleeds Vision Problems Asthma Ear Infections Contacts/glasses Pneumonia Headaches Hearing Problems Bronchitis Convulsions Dental Problems Tuberculosis Epilepsy Braces, Retainer Heart Murmur Speech Difficulties Serious Injury Anemia Diabetes X-rays Blood Disorder Kidney Disease Dislocations Frequent Colds Bladder Infections Fractures Sinus Congestion Hernia Chicken Pox Operations (type and date) Explanation: Date of last tetanus injection Fill out this next section only if the student intends to participate in sports or cheerleading: 1. Has any member of your family had a heart attack prior to age 50? 2. Do you have to stop while running around ¼ mile track twice? 3. Have you ever lost consciousness while participating in sports? 4. Are you taking any medications regularly? List: 5. Do you have any limitations, physical problems or congenital defects not already mentioned? List: 6. Have you ever had chest pain, difficulty breathing, coughing, dizziness, racing heart or skipped heartbeats during or after exercise? Explain 7. Do you tire more quickly than your friends during exercise? Parent signature Date 2/2011 Health History Form/Physical Exam Form 1 of 2

4 Bethel Baptist Christian Academy phone: 716/ Hunt Road fax: 716/ Jamestown, NY PHYSICAL EXAM FORM Page 2 to be completed by doctors, nurse practitioners, and clinics (or may use own form). NAME: Physical Examination: Height Weight BMI BMI% B/P Pulse Eyes Ears Lymph Nodes Thyroid Nose Tonsils Teeth Heart Lungs Abdomen Hernia Genito-Urinary Musculo-Skeletal Feet Skin Nervous System Speech Nutrition Comments Physician Signature Date This certifies that is physically qualified to participate in the following categories of interscholastic competition during the school year. (An unmarked box or boxes indicates disqualification for that group of activities). Contact or collision sports: Basketball, Soccer Endurance sports: Track, Cross Country, Volleyball Other sports: Cheerleading Reason for disqualification Date Physician Signature Physician Name (please print): 2/2011 Health History Form/Physical Exam Form 2 of 2

5 Bethel Baptist Christian Academy 200 Hunt Road Jamestown NY phone 716/ fax 716/ Dental Health Certificate Parent/Guardian: New York State law (Chapter 251) permits schools to request a dental examination in the following grades: school entry, K, 2, 4, 7 & 10. Your child may have a dental check-uo during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to the dentist for an assessment. If your child had a dental checkup before he/she started school, ask your dentist to fill out Section 2. Return the completed form to the school nurse as soon as possible. Section 1. To be completed by Parent or Guardian (Please Print) Child's Name: Last First Middle Birth Date: / / Sex: Male Grade Will this be your childs' first visit to month day year Female a dentist? Yes No Have you noticed any problem in the mouth that interferes with your child's ability to chew, speak or focus on school activities? Yes No I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student's dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health. I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below. Parent's Name (print) Parent's Signature Date Section 2. To be completed by the Dentist I. The Dental Health condition of on (date of exam). The date of the exam needs to be within 12 months of the start of the school year in which it is requested. Check one: Yes, the student listed above is in fit condition of dental health to permit his/her attendance at Bethel Baptist Christian Academy. No, the student listed above is NOT in fit condition of dental health to permit his/her attendance at Bethel Baptist Christian Academy. NOTE: NOT in fit dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at BBCA does not preclude the student from attending school. Dentist's name and address (please print or stamp) Dentist's Signature Optional Sections - If you agree to release this information to your child's school, please initial here. II. Oral Health Status (check all that apply). Yes No Caries Experience/Restoration History - Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR and open cavity). Yes No Untreated Caries - Does the child have an open cavity? [At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces considered sound unless a cavitated lesion is also present]. Yes No Dental Sealants Present Other problems (Specify): III. Treatment Needs (check all that apply) No obvious problem. Routine dental care is recommended. Visit your dentist regularly. May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation. Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems. 1 of 1 Dental Health Certificate 2/2011

6 Bethel Baptist Christian Academy Phone: 716/ Hunt Road Fax: 716/ Jamestown NY Protecting your kids is what you do. Keep them safe from the flu. Flu Guide for Parents You keep your child warm in the winter. And you make sure he or she eats well every day. So, keep your child safe from the flu, too. Get your child's flu shot every fall or winter. Is the flu more serious for kids? A flu shot may save your child's life. What is the flu? Flu shot or nasalspray vaccine? How else can I protect my child? What are signs of the flu? How does the flu spread? How long can a sick person spread the flu to others? Infants and young children are at a greater risk for getting seriously ill from the flu. That's why the New York State Department of Health recommends that all children 6 months and older get a flu vaccine. Most people with the flu are sick for about a week, and then they feel better. But, some people, especially young children, pregnant women, older people, and people with chronic health problems can get very sick. Some can even die. A flu vaccine is the best way to protect your child from the flu. The flu, or influenza, is a viral infection of the nose, throat, and lungs. The flu can spread from person to person. Flu shots can be given to children 6 months and older. A nasal-spray vaccine can be given to healthy children 2 years and older. Children younger than 5 years who have had wheezing in the past year --or any child with chronic health problems --should get the flu shot, not the nasal-spray vaccine. Children younger than 9 years old who get a vaccine for the first time need two doses. 1. Get the flu vaccine for yourself 2. Encourage your child's close contacts to get a flu vaccine, too. This is very important if your child is younger than 5 or if he or she has a chronic health problem like asthma (breathing disease) or diabetes (high blood sugar levels). 3. Clean your hands often and cover your coughs and sneezes. This will prevent the spread of germs. 4. Tell your children to: Stay away from people who are sick; Clean their hands often; Keep their hands away from their face, and Cover coughs and sneezes to protect others. It's best to use a tissue and quickly throw it away. If you don't have a tissue, cough or sneeze into your upper sleeve, not your hands. The flu comes on suddenly. Most people with the flu feel very tired and have a high fever, headache, dry cough, sore throat, runny or stuffy nose, and sore muscles. Some people, especially children, may also have stomach problems and diarrhea. The cough can last two or more weeks. People who have the flu usually cough, sneeze, and have a runny nose. The droplets in a cough, sneeze or runny nose contain the flu virus. Other people can get the flu by breathing in these droplets or by getting them in their nose or mouth. Most healthy adults may be able to spread the flu from one day before getting sick to up to 5 days after getting sick. This can be longer in children and in people who don't fight disease as well (people with weaker immune systems). 2/2011 Flu Document for Parents 1 of 2

7 Bethel Baptist Christian Academy Phone: 716/ Hunt Road Fax: 716/ Jamestown NY Flu Guide for Parents Page 2 What should I use to clean hands? What can I do if my child gets sick? Can my child go to school/day care with the flu? When can my child go back to school/ day care after having the flu? Wash your children's hands with soap and water. Clean them for as long as it takes to sing the "Happy Birthday" song twice. If soap and water are not handy, use wipes or gels with alcohol in them. The gels should be rubbed into hands until the hands are dry. Make sure your child gets plenty of rest and drinks lots of fluids. Talk with your child's doctor before giving your child over-the-counter medicine. If your children or teenagers may have the flu, never give them aspirin, or medicine that has aspirin in it. It could cause serious problems. No. If your child has the flu, he or she should stay home to rest. This helps avoid giving the flu to other children. Keep your child home from school/day care until his or her temperature has been normal for 24 hours. Remind your child to protect others by covering his or her mouth when coughing or sneezing. You may want to send your child to school with some tissues, wipes or gels with alcohol in them. For more information about flu, visit Or, Centers for Disease Control and Prevention State of New York Department of Health 2/2011 Flu Document for Parents 2 of 2

8 Bethel Baptist Christian Academy Phone: 716/ Hunt Road Fax; 716/ Jamestown, NY MEMO FROM THE NURSE: BMI As part of a required school health examination in grades K, 2, 4, 7 and 10, a student is weighed and his/her height is measured. These numbers are used to figure out the student s body mass index or BMI. The BMI helps the doctor or nurse know if the student s weight is in a healthy range or too high or too low. Recent changes to the New York State Education Law require that BMI an weight status group be included as part of the student s school health examination. A sample of school districts will be selected each year to take part in a survey by the New York State Department of Health. If our school is selected to be part of the survey, we will be reporting to New York State Department of Health information about our students weight status groups. Only summary information is sent. No names and no information about individual students are sent. However, you may choose to have your child s information excluded from this survey report. The information sent to the New York State Department of Health will help health officials develop programs that make it easier for children to be healthier. If you DO NOT wish to have your child s weight status group information included as part of the Health Department Survey, please send a signed copy of this form to the School Nurse Please DO NOT include any Body Mass Index (BMI) information on my child(ren) for New York State Department of Health surveys. Name of Child(ren) Parent Signature Parent name (please print) Date 1 of 1 Nurse BMI form 2/2011