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Current School: *

Parent/Guardian 1:

Street Address:

Parent/Guardian 2:

Do you give the ESY permission staff to photograph (photos/videos) your student?  (It may be used for publicity and/or classroom project purposes.)

Please answer each of the following questions about your child by checking the ‘yes’ or ‘no’ blanks to the right of each question.  If you chose, you may add a comment to finish answering the question.

a.  If yes, please list medication(s), purpose of medication, dosage & time it is to be given.  You must provide a physician’s script to have your child’s medication administered by the school nurse during the ESY program.  Medication must be in the original and labeled container(s).  Parent/Guardian must also provide written permission allowing the school nurse to administer medication(s).

10.  Please comment on any other information you would like our staff to know about your child (fears, dislikes, etc.)  Please include specific daily routines.

a. If yes, please list the name of the medication, dosage and time administered.  Please indicate how your child takes his/her medication.