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Emergency and Medical Information
In case of emergency, who should be contacted?
Relationship to Student
Phone # During
Does the student have any of the following?
(check al that apply)
□ Asthma □ Bone/Joint □ Bowel/Bladder □ Blood Disease □ Diabetes □ Ear Problems
□ Eating Concerns □ Emotional Problems □ Headaches □ Head Injuries □ Hearing Loss □ Heart Condition
□ Respiratory □ Seizures □ Speech □ Stomach □ Weight Concerns □ Vision ProblemsDoes the student require Special Equipment?
□ Glasses □ Stander □ Braces (AFOs) □ Hearing aids □ Wheelchair
□ Adaptive equipment for sitting □ Adaptive equipment for walking □ Other (specify) Other medical conditions of which the school needs to be aware of and/or hospitalizations or major surgeries in the past year:
Is your dependent Medicaid eligible? □ YES □ NOIf yes, provide Medicaid #
To comply with Colorado Law, please provide a copy of your student’s immunization record.
Tetanus/Diphtheria/Pertussis (Tdap) In Colorado, Tdap vaccine is required for all students entering 6th and 10th grades.
Pertussis or whooping cough can be a very serious disease in infants and smal children. It has been found that frequently, siblings who
have Pertussis disease can expose other children in the household. Colorado ranks fifth of al states in the country with this disease.
Varicel a or chickenpox is a disease that is very contagious, and there continue to be outbreaks of the disease in Colorado as wel as
other states around the country. Because of continued outbreaks, even in children who have had one injection of Varicel a vaccine, the
CDC has now recommended a routine second dose of Varicel a vaccine.
Emergency and Medical Information
Non-prescription Medication Administration:
Students may carry and self-administer non-prescription medication. They must not share their medication with
other students. Medication must be carried in its original packaging. CECFC nurses wil not give non-
prescription medications to students unless permission to administer the medication is authorized by the
parent/guardian. (Below) The school nurse is the only staff member who can give non-prescription medication
The parent/guardian of ___________________________ gives permission to the CECFC school nurse to
Administer the fol owing medication(s), according to manufacturer directions as needed by the student and
evaluated by the nurse, not more than every 4 hours.
Check all that apply: Acetaminophen (Tylenol) Ibuprofen (Advil) Naproxen (Aleve) Antacid (Tums)
It is understood that the medication is administered solely at the request of and as an accommodation to the undersigned parent/guardian. In consideration of the acceptance of the request to perform this service by and person employed by Colorado Springs Early Col eges, the undersigned parent/guardian hereby agrees to release Colorado Springs Early Col eges and its personnel from any legal claim which they now have or may hereafter have arising out of the administration of or failure to administer medication to the student. ____________________________
Parent/legal guardian’s printed name
Parent/legal guardian signature
Health Care Provider Authorization to Administer Medication in School:
Students may not carry prescription medication. It must be kept in the school nurse’s office. The medication
wil be provided by the parent/guardian in the original container in which it was purchased. In order for
prescription medication to be administered during school hours, the fol owing must be completed by the health
care provider and the parent/guardian. When ordering the medication, please ask the pharmacist to provide an
additional empty, labeled bottle to be stored at the school.
Student: ___________________________________________________ DOB: ____________________
Route: _____________________________To be given at fol owing time _________________________
Purpose of medication: _________________________________________________________________
Potential Side effects: __________________________________________________________________
Parent/Guardian Signature: ____________________________________________________________
Medical Provider Signature/Stamp: _____________________________________________________
Medication will not be administered without doctor’s signature.
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