• Health History for Children and Youth Attending School Age Programs

    Recreation Station
  • As required by K.A.R. 28-4-590(d) (1), each operator shall obtain a health history for each child or youth, on a form supplied by the department or approved by the secretary. Each health history is to be maintained in the child's or youth's file on the premises. As required by K.A.R. 28-4-590(d2), each operator shall require that each child or youth attending the program has current immunizations as specified in K.A.R. 28-1-20 or has an exemption for religious or medical reasons. Complete one form for each child or youth attending the School Age Program. 

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  • Person(s) authorized to pick up child in case of an emergency. This should NOT include Parents or Guardians.

  • Physician and Medication Information

  • Immunizations Status

  • If no to either of the above questions, you must email a copy of the child or youth's immunization history to the Program Supervisor: kayla@derbyrec.com

     

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  • I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this form is true and correct. 

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  • Authorization for Emergency Medical Care

  • Written permission for emergency medical treatment must be on file at the facility. Reference K.A.R. 28-4-127(b1A School Age Programs reference K.A.R. 28-4- 582(e2

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  • Health Insurance Information

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  • Medication Form

  • Authorization for Dispensing Medications to Children and Youth Long-Term Medications (Prescription and Non-Prescription)

    Prescription medications must be in their original containers labeled with the child's/youth's first and last name; the name of the licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN) who ordered the medication; the date the prescription was filled; the expiration date of the medication; and specific, legible instructions for administration and storage of the medication. Administer the medication only to the child designated on the prescription label in accordance with the instructions on the label. Non-prescription medications can be given with written permission and direction from the parent or legal guardian. Administer nonprescription medication from the original container labeled with the first and last name of the child/youth and according to the instructions on the label.

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  • Should be Empty: