Section 1 of 1 in this document

Allentown High School Health Form

(This form can be completed online or printed and returned to the main office.)

Health Office - Diana Ricciardi, R.N. - Phone: 609-259-7292, x1425; FAX: 609-223-4355

Student's FIrst Name

Student's Last Name

Grade

Father's Name

Father's E-Mail Address

Father's Cell Number

Mother's Name

Mother's E-Mail Address

Mother's Cell Number

Does your child have a severe allergy (bee sting, food, medication, other)?

Yes

If Yes, type of Allergy

If Yes, what treatment is necessary?

Medication

Hospitalization

Both

If your child has any other health problem or physical limitation, please notify the school nurse.

Check consent for school nurse to administer medication during school day. (The school nurse is authorized to decline to administer a medication if the situation warrants.)

Medication Consent: I authorize the school nurse to administer the following medication.

Acetaminophen

Benadryl

Ibuprofen (ages 12 and over)

The State of New Jersey requires that we ask the following questions:

If you have medical insurance, the Name of Provider

I have read this form completely and hereby give permission for my child to have those medications to which I have consented on this form.

Regarding Student Drivers: In the event your child become ill, this serves as written permission to permit your child to sign out of school and drive home provided they are physically able. Parent/Guardian will also be called for verbal permission to release student.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Allentown High School Health Form

Health Office - Diana Ricciardi, R.N. - Phone: 609-259-7292, x1425; FAX: 609-223-4355

Full Address

Does your child have a severe allergy (bee sting, food, medication, other)?

If Yes, what treatment is necessary?

Medication Consent: I authorize the school nurse to administer the following medication.

Full Name

Sign Here

Full Date