Leverett Elementary School
85 Montague Road
Leverett, Massachusetts 01054
(413) 548-9144
STUDENT HEALTH INFORMATION
Student’s Name ____________________________________________ Grade ___________
Please complete this form and include:
▢ a copy of your child’s updated immunization record if any changes
▢ a recent physical exam for all preschool, kindergarten, 4th grade, and new students
Primary Care Provider Name ______________________________ Phone ________________
Dentist Name __________________________________________ Phone ________________
Please check all that apply to your child:
▢ Allergies ▢ Asthma ▢ Concussion ▢ Dental Problems
▢ Diabetes ▢ Headaches ▢ Heart Problems ▢ Mental Health Concerns
▢ Orthopedic Issues ▢ Seizures ▢ Vision/Hearing Needs ▢ Other
If you checked any of the above boxes, please explain: ___________________________________
________________________________________________________________________________
________________________________________________________________________________
Does your child have any food restrictions? _____________________________________________
Please list all medications your child takes: _____________________________________________
I give permission for my child to use hand sanitizer at school.
I give permission to the nurse to share information relevant to my child’s health with appropriate school
personnel when needed to meet my child’s health and safety needs. I give permission to exchange
information with my child’s health care provider for the purpose of referral, diagnosis, and treatment.
Parent/Guardian Signature: ________________________________________ Date: ____________
Permission to Use Standing Orders for Over-The-Counter Medications
The following over-the-counter medications are available as needed in the school health office. These
medications may only be administered by the school nurse, and will be dosed appropriately according to
age/weight of student. If a student uses any of the below medications on a regular basis, the
parent/guardian will be asked to supply the medication from home. The school nurse will always attempt
to contact a parent/guardian before administration of Tylenol or Advil.
My child may receive the following medications as needed during the school day:
▢ Acetaminophen (Tylenol) ▢ Ibuprofen (Advil) ▢ Cough drops
▢ Calamine Lotion ▢ Eucerin Lotion ▢ Bacitracin Ointment
▢ Do not give my child any of the above listed medications
Parent/Guardian Signature: ________________________________________ Date: ____________