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Career Academy South Bend Health Services
Please return this form to the S chool Nurse
3801 Crescent Circle
South Bend, IN 46628
Phone: (574)299-9800 Ext. 3104 Fax: (574)288-6125
HEALTH OFFICE PACKET
(Please read over all of the following information prior to completing and turning in your registration packet)
Indiana State Law requires that all students be properly immunized for the health and safety
of all students. You must provide the school with a complete and up to date copy of all of
the required immunizations. The copy must be documented by your health care provider,
health department where the child received the immunizations, or must be from an
official copy of the official immunization record from the child's previous school.
The record must include ALL of the following immunizations:
Kindergarten
Grades 1 through 5
Grades 6 through 11
12th Grade
3
5
4
3
5
4
2
3
5
4
2
3
5
4
2
Hepatitis B
DTap
Polio
Hepatitis B
DTap
Polio
MMR
Hepatitis B
DTap
Polio
MMR
Hepatitis B
DTap
Polio
MMR
2
2
2
2
2
1
MMR
Varicella
*Hepatitis A
Varicella
*Hepatitis A
Tdap
2
2
1
1
2
2
1
2
Varicella
*Hepatitis A
Tdap
MCV
Varicella
*Hepatitis A
Tdap
MCV
* This vaccine is a new requirement for the 2015-2016 school year.
If a complete and up to date copy of ALL of the above immunizations is not provided within
20 days of the start of school, your child will be excluded from school starting the 21 st day
and will continue to be excluded until this information is provided and the nurse has verified
the record is complete or proof of a medical appointment has been made.
If you have further questions or concerns about immunizations, contact the school health staff.
Last Revised 1/2015
Career Academy South Bend Health Services
Please return this form to the S chool Nurse
3801 Crescent Circle
South Bend, IN 46628
Phone: (574)299-9800 Ext. 3104 Fax: (574)288-6125
STUDENT HEALTH HISTORY AND EMERGENCY INFORMATION
Please notify the school of any changes to the information you provide below.
Date of Birth:
Home Phone:
Name:
Address:
Parent/Guardian:
Cell:
Work:
Email:
Cell:
Work:
Email:
Parent/Guardian:
The following persons have permission to pick this student up from school:
Name
Relationship
Has this student ever had chicken pox?
Physician:
Preferred Hospital:
Yes
Home/Cell Number
No
Work Number
If yes, when? _______________________
Phone:
Medical History
Does this student have any of the following conditions:
Asthma
Seizures
Ear Infections
Migraines
Hearing Loss
Diabetes
Frequent Nose Bleeds
Frequent Headaches
Stomach Problems
Scoliosis
Does this student have any Allergies?
ADD
ADHD
Heart Condition
Vision Difficulty/ Glasses
Other: _____________
Yes
Please describe any conditions I need to be
aware of to care for your child _________________
__________________________________________
__________________________________________
__________________________________________
No If yes, __________________________________
Daily Home Medications:
Daily School Medications:
The Health Servi ces Pl an makes provision for health record, nursing consultation, emergency ca re treatment a nd non-invasive screen
(i .e., hearing, vi sion, height and weight measurement). Any parent wishing to opt their child out of a screening must do s o i n writing. Temperature
s creening will be done i f deemed necessary. Pa rent/guardian has the responsibility of listing any a llergies.
In ca se of serious illness or i njury where immediate ca re is needed, the school or i ts representative has my permission to co ntact the
a ppropriate emergency medical service. The emergency medical s ervice has my consent to provide necessary treatment or tra nsportation for my
chi l d. I then request that I be notified of the situation. The undersigned will be responsible for emergency trea tment cost.
In the case of an accident or illness where i mmediate treatment of my child is not i ndicated, but where he or s he is unable to remain at
s chool, I request that the s chool contact me or my designee to a rrange tra nsportation for my chi ld. If the school is unable t o contact me, I request
tha t one of the other persons listed on this ca rd be contacted and requested to ca re for my child. In the event no person designated on this care i s
a va ilable, emergency medical servi ces may be contacted for further assessment and possible transport a nd treatment.
I understand that certain educational records of my child will be shared with Ca reer Aca demy South Bend’s (CASB) healthcare partners as
needed to provi de and evaluate health s ervices to students. I also understand and a gree that my child’s medical treatment rec ords created by CASB
hea lthcare personnel at CASB may be shared with school officials who have a legitimate educational purpose for accessing s uch records.
Date: _______________ Signature of Parent/Guardian: ____________________________________________________________
Last Revised 1/2015
Career Academy South Bend Health Services
Please return this form to the S chool Nurse
3801 Crescent Circle
South Bend, IN 46628
Phone: (574)299-9800 Ext. 3104 Fax: (574)288-6125
PARENT REQUEST FOR ADMINISTRATION OF
OVER-THE-COUNTER MEDICATION
Only those medications that are medically necessary during school hours for a student’s attendance or written in an IEP
should be sent to school. The parent/guardian must provide the medication in the original container and properly
labeled with student’s first and last name. This form is good for one school year and must be renewed yearly.
Medication is not kept over the summer. Any medication remaining in the Health Office is properly discarded after the
last day of school.
THE VERY FIRST DOSE OF ANY MEDICATION WILL NOT BE GIVEN AT SCHOOL. IF YOUR CHILD HAS NEVER TAKEN THIS
MEDICATION AT HOME THEY WILL NOT BE GIVEN IT HERE AT SCHOOL.
I am the parent/guardian of the child named below and I am acting on behalf of this minor child. I hereby authorize and
agree to hold the Career Academy South Bend and its officers and employees harmless for the administration of the
following medication:
NAME OF STUDENT: _______________________________________________________________ DATE OF BIRTH: _____________
(Hand written on a non-prescription container.)
NAME OF MEDICATION & STRENGTH: ____________________________________________________________________________
DOSAGE (amount): ___________________________________________________________________________________________
TIME TO BE GIVEN AT SCHOOL: _________________________________________________________________________________
REASON OR HEALTH PROBLEM: _________________________________________________________________________________
MEDICATION TO BE GIVEN FROM: __________________________________ TO : _______________________________
(Date)
(Date)
I understand that by operation of law, specifically Indiana Code 34 -30-14-2, a Career Academy South Bend employee or staff
member administering medication in accord with the permission statement and the Career Academy South Bend shall be immune
from all liability for acts arising out of the administration of medication in accord with the terms of this document, except in the case
of gross negligence or willful and wanton misconduct.
In addition to the immunity described above, in exchange for Career Academy South Bend’s agreement to assume responsibility
for the administration of medication as described in this permission statement, we hereby release any and all clai ms that we may
lawfully release at this time for acts or omission arising out of the administration in accord with this grant of permission.
_________________________________________
________________________
PARENT’S/GUARDIAN’S SIGNATURE
DAYTIME PHONE
Reviewed by RN: ____________
(Date)
Staff ___may
___may not administer
_______________
DATE
_________________________________________
RN (SIGNATURE)
Administration of Medication - Indiana Statute 1C 34-4-16.5-3.5
All medication (prescription and non-prescription) shall be administered in compliance with Indiana Statute lC 34 -4-16.5-3.5.
The requirements of this act are as follows:
1. Only employees designated by the school administrator are qualified to give any medication and the medication must be admi nistered by the school
employee in the presence of another adult.
2. The term “medication” includes over-the-counter medication such as Aspirin, Tylenol, Ibuprofen and cough drops.
3. Written permission of parents or guardians is required.
4. All written permissions must be kept on file at school. A new permission form must be submitted each school year.
5. It is the parent or guardian’s responsibility to inform the school of any medication needed by their child and provide necessary written permission
required by law.
6. All medication (prescription and non-prescription) must be kept in the secured area designated by the building Principal.
7. All medication (prescription and non-prescription) shall be administered through this policy.
STUDENTS ARE NOT TO CARRY ANY MEDICATION ON THEIR PERSON DURING THE SCHOOL DAY .
Last Revised 1/2015
Career Academy South Bend Health Services
Please return this form to the S chool Nurse
3801 Crescent Circle
South Bend, IN 46628
Phone: (574)299-9800 Ext. 3104 Fax: (574)288-6125
PHYSICIAN AND PARENTAL AUTHORIZATION TO ADMINISTER
PERSCRIPTION MEDICATION
The following information is necessary for any student to be given any prescription medications in school.
All spaces must be completed.
Name of Student: ___________________________________________________
Date of Birth: ___________
I am the parent, with legal custody, or the legal guardian of the above named student. I am requ esting permission for
my child to take medication at intervals during the school day. I hereby give my consent and authorize the school nurse
or other designated school employee to:
PHYSICIAN’S AUTHORIZATION FOR PRESCRIPTION MEDICATION
I. Administer ___________________________________, a prescription medication, which I am hereby supplying the school in the
original prescription container with the student’s name, in accordance with the directions for the administration of the medicine
listed on the label of the container.
(Requires parent and physician’s signature)
Medication
Dosage
Frequency
Route
_______________________________
_________________
__________________
____________________
Precautions/Possible side effects: _____________________________________________________________________
_____________
______________________________________
Date
____________________
Physician’s Signature
Phone Number
II. I will assume responsibility for safe delivery of the medication to school
III. I will notify the school immediately if there is any change in the use of the medication or the prescribed treatment.
IV. Medications must be picked up at the end of school year by parent, or medication will be destroyed.
I release and agree to hold Career Academy South Bend, its officials, and its employees harmless from any and all liability for
damages or injury resulting directly or indirectly from this authorization.
___________________________________________________
_______________
Parent with Legal Custody or Guardian
Home Phone ___________________
Cell Phone ___________________
Date
Work Phone ___________________
Administration of Medication - Indiana Statute 1C 34-4-16.5-3.5
All medication (prescription and non-prescription) shall be administered in compliance with Indiana Statute lC 34 -4-16.5-3.5.
The requirements of this act are as follows:
1. Only employees designated by the school administrator are qualified to give any medication and the medication must be administered by
the school employee in the presence of another adult.
2. The term “medication” includes over-the-counter medication such as Aspirin, Tylenol, Ibuprofen and cough drops.
3. Written permission of parents or guardians is required.
4. All written permissions must be kept on file at school. A new permission form must be submitted each school year.
5. It is the parent or guardian’s responsibility to inform the school of any medication needed by their child and provide necessary written
permission required by law.
6. All medication (prescription and non-prescription) must be kept in the secured area designated by the building Principal.
7. All medication (prescription and non-prescription) shall be administered through this policy.
STUDENTS ARE NOT TO CARRY ANY MEDICATION ON THEIR PERSON DURING THE SCHOOL DAY .
All medication brought to school should be delivered immediately to the school office for its safekeeping and administration.
Last Revised 1/2015
Career Academy South Bend Health Services
Please return this form to the S chool Nurse
3801 Crescent Circle
South Bend, IN 46628
Phone: (574)299-9800 Ext. 3104 Fax: (574)288-6125
C.H.I.R.P
(Children and Hoosiers Immunization Registry Program
Release Form
I,
, give the Career Academy South Bend , permission to
release the following information concerning my child, _____________________________ , to the Indiana
State Department of Health’s Children and Hoosiers Immunization Registry Program (CHIRP):
-NAME
-DATE OF BIRTH
-CURRENT ADDRESS
-CURRENT PHONE NUMBER
-IMMUNIZATIONS RECEIVED AND THE DATES THEY WERE ACQUIRED
I understand that the information in the registry may be used to verify that my child has received proper
immunizations and to inform me or my child of my child’s immunization status or that an immunization is due according
to recommended immunization schedules.
I understand that my child’s information may be available to the immunization data registry of another state, a
healthcare provider or a provider’s designee, a local health department, an elementary or secondary school, a child care
center, the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning, a licensed
child placing agency, and a college or university. I also understand that other entities may be added to this list through
amendment to I.C. 16-38-5-3.
By signing I hereby consent to the release of such information.
Signature
Date
Printed Name of Parent or Guardian
Address
Child’s Name
Career Academy South Bend
School
Last Revised 1/2015