Permission to Treat / Health Appraisal From

A seperate form needs to be completed for each student.

Student First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Grade REQUIRED Please fill out this field. Please enter valid data.

I hereby give consent for St. Mary’s School to verify dates of medical appointments as needed and for school personnel to administer to my child the following as deemed necessary to be in the best interest of my child.
- Give minor treatment.
- Obtain services of a physician or hospital care in case of emergency.
- Disclose pertinent health information to necessary staff members.

Further, I hereby give St. Mary’s permission to release the name, immunization data, DOB, address, or other identifying information as applicable concerning the above child to the Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (CHIRP). 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.

I Agree Please select this field.

Signature REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Child's Doctors Name REQUIRED Please fill out this field. Please enter valid data.

Doctor's Phone Number REQUIRED Please fill out this field. Please enter a phone number.

IMPORTANT: The parent or legal guardian is responsible for assuring the medication arrives safely to school in the original pharmacy labeled container.

Describe other health condition:

1. Current Medications:

What medications are given daily at home?

Medication #1 Dosage and Frequency

Medication #2 Dosage and Frequency

Why are these medications prescribed?

What medications are needed during school?

Medication #1 Dosage and Frequency

Medication #2 Dosage and Frequency

Why are these medications prescribed?

2. Allergies:

My child is allergic to:

Check : The student does not require an emergency allergy medication at school The student will carry an emergency Epi-Pen on self – requires a permission slip from doctor and care plan. The student does require treatment/medication which I will bring to school. Treatment for the allergy:

Treatment for the Allergy: Benadryl Epi-Pen (Care plan required) Other

Other: Please enter valid data.

3. Athsma/Reactive Airway Disease:

(complete only if your child has been diagnosed with this condition):

Check: The student does not require an emergency inhaler at school. The student will keep an emergency inhaler in the school office. The student will need to use an nebulizer as needed at school. The student will carry an emergency inhaler on self – requires a permission slip from doctor.

4. Seizures:

(complete only if your child has been diagnosed with this condition):

Select one: The student does not require seizure medication at school. The student will have medicine to be kept in the school office if needed for an emergency. (Care plan required)

Neurologist’s Name: Please enter valid data.

Neurologist’s Phone Number Please enter a phone number.

5. Other:

Any hospitalization/surgery/major illness/major accident or injury? Emotional or behavioral problems?

Please explain:

St. Mary's Preschool