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YES NO YES NO Allergies (for example, food, medication, hay fever, other) If yes, please list: 12. Digestive/Stomach Problems 2. Uses an inhaler for asthma? If yes, circle one: regular/ occasional/ will use @ school 13. Any Psychological/Emotional Concerns (please explain) 3. Skin Conditions 4. Seizures/convulsions 5. Heart Problems 14. Any other problems/concerns of which we need to be aware and/or please explain any  yes answers. 6. Diabetes 8. Serious Injury 15. List medications currently taken by student and reason for use. 9. Congenital Defects 10. Dental Problems 11. Vision Problems Doctor/Clinic Name: ___________________________________________ Telephone Number: _____________________ The Monroe County Community School Corporation employs Registered Nurses (RN s). RN s (in the elementary/middle schools) and RN s or appointed school health care personnel (in the high schools) may dispense aspirin, aspirin substitutes or other non-prescription medications when in their professional judgment such remedies are warranted, unless the parent/guardian or physician have given instructions to the contrary. Prior to dispensing such medication, the school nurse shall inquire of the student whether they are allergic to these medications. Should the above student become ill or injured, while in school or on a field trip, first-aid will be given. Further care must be assumed by the parent/guardian. In the event of an emergency, 911 may be called and the school will make reasonable attempts to reach the parent/guardian. The undersigned parents or custodial parent and natural guardian or guardian or court appointed guardian, hereinafter called APPOINTER, of ___________________________________ (student), hereinafter called MINOR, having the authority to give consent for medical treatment of MINOR, pursuant to I.C. 16-36-1-7 hereby appoints Monroe County Community School Corporation Sponsors as the representative of Appointer to act in Appointer s stead in giving consent in matters affecting health care of Minor. A separate medication authorization form is required for any medication brought in by the parent/guardian. Medications are not allowed to be brought in by students. This medication authorization form and further information regarding medications in the schools may be found on the MCCSC website (http://www.mccsc.edu/~healthy/ or http://www.mccsc.edu, click on  Academics , Programs & Activities, Healthy Schools, Health Services) or may be obtained from your school s health office. I ALLOW MY CHILD TO BE TREATED FOR ILLNESS/INJURY AND BE GIVEN NON-PRESCRIPTION MEDICATIONS and hereby give my permission for the school to obtain medical services in a licensed hospital by a licensed physician(s) in case my child suffers illness or accident while participating in a school event, and the parent/guardian cannot be reasonably contacted. Parent/Guardian Signature __________________________________________________________ SIGNATURE OF PARENT/GUARDIAN REQUIRED FOR TREATMENT AT SCHOOL OR SCHOOL EVENT OR ACTIVITY. Original to be kept in building health office ADM/GEN 12 REF POLICY 5341 Revised 02-23-2009 aN1כN1כD "$h ,9"D "@01(N1כ||edications. Should the above student become ill or injured, while in school or on a field trip, first-aid will be given. Further care must be assumed by the parent/guardian. 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