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Upper Freehold Regional School District

27 High Street, Allentown, NJ, 08501, US


Stone Bridge Middle School Health Form

Health Services Office Jacqueline Mulryne, R.N. Phone: 609-259-7292, x5102 FAX: 609-223-3642

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

If Yes, what treatment is necessary?

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.

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.

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