ACS Nurse's Office

To:          ACS Parents/ Guardians
From:     Linda Bernard, RN, MS, CSN
Re:         Health, Physical and Medication Permission Forms and School Health Information

Below are the forms that needed to be completed for the School Nurse’s Office for the school  year. 

Physical Examination form,  Medical History Questionnaire, Dental Examination Form 

Pre-K Registration Forms

Registration for Pre - K.doc
Physical Examination Form - Pre-K.doc
Dental Examination Report for Registration.doc
Medical History Questionnaire for Pre-K.doc

Kindergarten - 5th Grade Registration Forms
Registration for School Entry K-5
Physical Examination Form.doc
Dental Examination Report for Registration.doc
Medical History Questionnaire.doc

These forms are required for all incoming students.  The forms are due in the nurse’s office at the time of entry.

Fourth Grade Physical Examination Form & Medical History Questionnaire 

4th Grade Physical Requirement.doc
Medical History Questionnaire.doc
Physical Examination Form.doc

This physical is a requirement for all 4th grade students. These forms are due in the nurse’s office by October 15th.

Medication Administration Orders
Medication Administration Form.doc
Medication Administration form for Epinephrine.doc
Asthma Action Plan.pdf

Medication Administration Permission Form
 

If your child needs to take medication daily or occasionally during the school year, please have your doctor complete this form.  All medication administration, including over the counter medication requires this form to be completed by your child’s doctor. The form must also be signed by a parent. Medication must be brought to the nurse by a parent. All medication should be in the original pharmacy container.

Allergy Medication Administration Permission Form
If your child is prescribed an epinephrine auto-injector for allergy, please have your doctor complete this form. Your doctor may also complete the portion of this form for self-administration of both the epinephrine and an antihistamine if he/she feels your child is able to self-administer. This form must also be signed by a parent.

Asthma Action Plan
If your child has a history of asthma, uses an inhaler or a nebulizer, please have your physician complete the asthma action plan. Your doctor should also complete the self-administration portion of this form if he/she feels your child is able to self-administer the medication.

Permission to Share Information
Permission to Share Medical Information.doc

If your child has any medical issues that may impact him/her in the classroom, this form gives me permission to share pertinent medical information with other school personnel. This is to protect the health and safety of your child.

School Health Information

Sick Day Guidelines – When to keep your child home from school.
Sick Day Guidelines - Making the Right Call.doc

If your child has illness symptoms during the previous night, consider making arrangements for your child to remain at home. Rest and early attention will often shorten the illness.  It will also help cut down on the spread of germs at school.  Sending a sick child to school not only endangers the health of all others but also increases your child’s susceptibility to other illnesses to which they may be exposed.

Consider keeping your child home if he or she:

  • Has a fever of 100 degrees or higher
  • Vomiting and/or diarrhea within the past 24 hours
  • Has symptoms that prevent him or her from participating in school, such as:
    • Excessive tiredness or lack of appetite
    • Persistent coughing that could be distracting to your child and disruptive to the class.
    • Headache, body aches, earache
    • Unexplained rashes, sores, and crusty, inflamed eyes or other signs of contagious illness
    • Cold or runny nose if nasal discharge is excessive and/or not clear.
    • Sore throat
      a minor sore throat is usually not a problem, but a severe sore throat could be strep throat even if there is no fever. Other symptoms of strep throat in children are headache and stomach upset. Contact your pediatrician as your child needs a special test to determine if it is strep throat.  If you are awaiting results of a strep culture, please keep your child home from school until results have been received. Positive results must be on antibiotics a full 24 hours before return to school.

Gym Excuses
Parents may request, in writing, a gym excuse for up to 3 days for a student that has a medical problem that does not appear to require a physician's care. After 3 missed gym classes, a physician's note is required for further excuse from gym.

Injuries
If your child is returning to school with an injury, please obtain a doctor's note for the absence. CRUTCHES: A physician's note is required for the student who needs crutches. The note must clearly state that the student is allowed to use crutches in school.

CASTS, SLINGS & SPLINTS: A physician's note is needed. It must state the nature of the injury, any limitations or restrictions and the dates the student is excused from physical education and recess.

Communicable Diseases
Elementary schools can be germ factories! Hand washing is important to reduce the spread of germs. Practice and reinforce this healthy habit at home.  For the health of all our students and staff, please let me know whenever your child has been diagnosed with any communicable disease. These include head lice, strep throat, pink eye, chicken pox, impetigo and ringworm. This information will be kept confidential.

Head Lice
Head lice are a nuisance in all schools. It is the parent's responsibility to check their child's hair and treat, if needed.  Periodic checks may be conducted if needed. Communication with parents will be as necessary. If you suspect head lice, please call me. Regular communication between school and home helps to keep this pest to a minimum.

If you have questions or would like to discuss your child’s health issue with me, please call me at 201-302-5200 ext: 2207. Forms can be mailed or dropped off at the school to the attention of Mrs. Linda Bernard, School Nurse, Anna C. Scott School or you can email them to me at bernard@leoniaschools.org.