Medical Consent Form 2024-2025

Medical Consent Form 2024-2025
Student Name*
Date of Birth*
Grade*
Do you consent for the nurse or health assistant to test for a communicable disease on-site if symptoms exist for the following?

-Low Blood Glucose (low blood sugar)

-Strep A, Flu A/B, COVID

-Urinary symptoms
Do you consent to testing?*

YesNo
You will be notified of test results and if your child needs to go home or can remain at school. All students exhibiting communicable symptoms will be asked to wear a mask while in class.

Do you consent for your child to receive a weight-based, age appropriate dose of OTC medication, such as Tylenol, Benadryl, Ibuprofen or TUMS for minor situations if not resolved naturally?
Do you consent to medication?*

YesNo
YOU WILL BE PERSONALLY NOTIFIED OF ANY IDENTIFIED INJURY OR PROBLEM, THIS FORM IS INTENDED FOR MINOR SITUATIONS AND MEANS OF TESTING. THANK YOU!
PARENT SIGNATURE*

Clear
PARENT/GUARDIAN NAME:*
DATE*

MonthDayYear
Date
NURSE BETSY: 575-776-2256, email: bconiglio@anansi.acstaos.org
Should be Empty: