School Year:<\/strong> __________________<\/p>\n Student Name:<\/strong> <\/p>\n Date of Birth:<\/strong> <\/p>\n Physician\u2019s Name:<\/strong> <\/p>\n Phone #:<\/strong> <\/p>\n Address:<\/strong> <\/p>\n Fax #:<\/strong> <\/p>\n List Known Allergies:<\/strong> <\/p>\n Brief Description of Condition:<\/strong> <\/p>\n Current Medications:<\/strong><\/p>\n Special Equipment:<\/strong> <\/p>\n Symptoms Child May Demonstrate:<\/strong><\/p>\n Vital Sign Parameters:<\/strong><\/p>\n Limitations:<\/strong><\/p>\n Cleared without limitations including all physical activities and recess.<\/p>\n Not Cleared for (please be specific): <\/p>\n If the student complains of chest pain, shortness of breath, and\/or has vital signs outside acceptable parameters, school personnel should immediately:<\/p>\n Nursing services are recommended for the care of this student during the school day.<\/p>\n Physician’s Signature:<\/strong> <\/p>\n Date:<\/strong> <\/p>\n For (Student Name):<\/strong><\/p>\n Is your child compliant with their current treatment regime?<\/strong> Yes \/ No<\/p>\n Does your child function independently with medication administration?<\/strong> Yes \/ No<\/p>\n Are there any activity restrictions for your child?<\/strong> Yes \/ No<\/p>\n If yes, please list: <\/p>\n I authorize my child\u2019s school nurse to assess my child as it relates to his\/her special health care needs and to discuss these needs with my child\u2019s physician as needed throughout the school year. I understand this is for the purpose of generating a health care plan for my child. I understand I may withdraw this authorization at any time and that this authorization must be renewed annually. As the parent or guardian of the student named above, I request that the principal or principal\u2019s designee assist in the administration of medication\/treatment prescribed for my child. I understand that under provisions of Florida Statute 1006.062, there shall be no liability for civil damages as a result of the administration of medication when the person administering such medication acts as an ordinarily reasonable, prudent person would have acted under the same or similar circumstances. I also grant permission for school personnel to contact the physician listed above if there are any questions or concerns about the medication. I have read the guidelines and agree to abide by them. I authorize the physician to release information about this condition to school personnel.<\/p>\n Parent\/Guardian Signature:<\/strong> <\/p>\n Print Name:<\/strong> <\/p>\n Date:<\/strong> <\/p>\n Parent\/Guardian Contact Information:<\/strong><\/p>\n Cell:<\/strong> <\/p>\n Work:<\/strong> <\/p>\n Parent\/Guardian Contact Information:<\/strong><\/p>\n Cell:<\/strong> <\/p>\n Work:<\/strong> <\/p>\n","protected":false},"author":429,"template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-526","savoy_document","type-savoy_document","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/526","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document"}],"about":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/types\/savoy_document"}],"author":[{"embeddable":true,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/users\/429"}],"version-history":[{"count":0,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/526\/revisions"}],"wp:attachment":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/media?parent=526"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Medical Details<\/h2>\n
\n\n
\n \nName<\/th>\n Dosage\/Route<\/th>\n School<\/th>\n Home<\/th>\n<\/tr>\n<\/thead>\n \n <\/td>\n <\/td>\n <\/td>\n <\/td>\n<\/tr>\n \n <\/td>\n <\/td>\n <\/td>\n <\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n \n
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Emergency Procedures<\/h2>\n
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Continued Cardiac Plan<\/h2>\n
Authorization for Health Care Provider and School Nurse<\/h2>\n