DATE: April, 2009
TO: Timberlane Parents
In order to be sure that all essential school personnel have the information to help your child in an emergency situation, the Superintendant of Schools has requested that medical/health alerts be entered into the central database called “Powerschool”. This is a protected program that allows password access to Administrators, their assistants, Guidance Counselors and classroom teachers (for their classroom group only). The database already holds the contact information that you have recorded for the school. In an emergency, Principals will carry their handheld PDA’s containing that information. Adding the following details completes their ability to anticipate the response necessary for your child.
This information is Confidential and is treated as such by school personnel. Please return the form to the School Nurse. Feel free to put it in a sealed envelope if you choose to do so.
Please complete the form below by circling the life threatening condition or “NONE OF THE ABOVE”.
Student Name:__________________________________Grade: ____ Teacher:__________________________________
ALLERGY
TO BEES – Severe/has Epi-Pen at school or on person
ALLERGY
TO FOOD – Severe/has Epi-Pen at school or on person
ALLERGY
TO COLD OR HEAT – Severe/has Epi-Pen at school or on
person
ASTHMA
– has inhaler at school/or on person
DIABETES
BLEEDING
DISORDER
SEVERE
BREATHING/RESPIRATORY DISORDER
CARDIAC/Heart
Disease –with activity restrictions
CEREBRAL
PALSY
SEIZURE
DISORDER- Emergency medication at school
Medical
Condition: NONE OF THE ABOVE
Parent Signature____________________________ Date________________