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Health

Nurse Contact Numbers

Elementary Nurse (grades K-5): 385-2118 (Option 3) Middle School/High School Nurse (grades 6-12): 385-2189 (Option 3)

Health Documents and Information for School

Administration of Medication Permission Form
Medical Statement Form
Medical Statement Letter from Nurse Gordan

Administration of Medication Permission Form

Administration of Medications Permission Form

Required

School Building Name: *required

Date Received by the school: *required

Student Name*required

First Name

Last Name

Date of Birth: *required

Age: *required

Homeroom/Classroom & Grade: *required

Please list any medical information you would like the district to be aware of in order to adequately assist your student in an emergency (For example: medication alerts, allergies, etc). *required

Medication/Prescription Information *requiredPlease select up to 2 choices

Prescription Medication

Over-the-Counter Medication Provided by parent/guardian

Please select up to 2 choices

Name of medication and brief reason for taking this medication: *required

Form of medication/treatment: Please select up to 6 choices

Tablet/capsule

Liquid

Inhaler

Injection

Nebulizer

Other

Please select up to 6 choices

Describe schedule and dose to be given at school: *required

If "as needed," indicate the maximum dosage per day: *required

Restrictions and/or important side effects? Please indicate in this space: *required

Special Storage Requirements: *requiredPlease select up to 3 choices

None

Refrigerate

Other

Please select up to 3 choices

If special Storage requirements, please describe:

Physician's Name*required

First Name

Last Name

Physician's Address & Phone/Fax Number *required

Parent/Guardian Note and Signature---I give permission for my child to receive the above medication at school. I also give district employees permission to contact the student's physician directly to provide information on the student's condition. I understand that I have the ultimate responsibility for providing the school with an adequate supply of medication and for informing the school district immediately if any information provided on this form changes or if administration of medication should cease. In the space below please type your name as an "electronic signature." *required

Parent/Guardian Home and Work Phone Numbers: *required

Emergency Phone Number: *required

Medical Statement Form

Medical Statement Form

Medical Statement Letter from Nurse Gordan

MedicalStatementLetter.pdf

Macon County R-I School District Central Office

Mailing Address: 702 North Missouri St.

Physical Address: 902 North Missouri St., 3rd Floor Office Spaces (Entrance in the Back)

Macon

MO

63552

660-300-6147 | Fax

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