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Boston Preparatory Charter Public School 1286 Hyde Park Avenue, Hyde Park MA 02136 Dear Boston Prep Parent/ Guardian, Time to start planning for the 2013-2014 school year! The following information is VERY IMPORTANT:  Please COMPLETE ALL OF THE FORMS provided in this packet.

Remember that the nurse cannot administer ANY medications (such as
tylenol, motrin, Benadryl, etc) without a prescription from your health
care provider.

Make sure that your student has had a physical in the last 12 months.
 Encourage your student to wear sunscreen, at least SPF15. Everyone, regardless of race and ethnicity is at risk for skin cancer with sun exposure, even on a cloudy day.  Drink LOTS of water (juice and soda does not count!).  If your student has food allergies and/or asthma, remind your student to bring Please feel free to contact me at (617) 333-6688 with any questions or concerns you may have. Sincerely, Haley Claflin, RN Boston Preparatory Charter Public School 1286 Hyde Park Avenue, Hyde Park MA 02136 Medication Authorization Form
Under Massachusetts General Laws (MGL) Chapter 112, Section 80B, a licensed nurse must have a
medication order from a physician, dentist, nurse practitioner, or physician’s assistant in order to
administer any prescription medication and any over-the-counter (OTC) medication (such as
Tylenol, Advil, Tums, Benadryl, etc)
A licensed prescriber’s form may be used instead of the one below, however, it must be signed by
the provider AND the parent/guardian.

Licensed Prescriber’s Written Medication Order (for EACH medication):
Student name: ______________________________________________ Grade: ______ DOB:

Medical diagnosis/Reason for medication: ____________________________________________
Medication: ______________________________________________ Dose: ________________
Route: _______________ Frequency: ____________ Time to Administer at School: ___________
Start date: ________________
Duration of order: (all orders expire at the end of the school year): ____________ Consent for Self-Administration of Medication (provided the School Nurse determines it is safe and appropriate) Signature of Licensed Prescriber: ________________________________________, MD, NP, Other ____ Print Name: _______________________________________ Tel: _________________ Date: _________ Parent/Guardian Consent:

Parent/Guardian Signature: _________________________________________
Print Name: _______________________________________ Tel: _________________ Date: _________
Emergency Contact: _______________________________________ Tel: _________________
*Please bring this form into school or fax it to BPCPS, Attn: Haley Claflin, RN at 617-333-6689.*
Boston Preparatory Charter Public School 1286 Hyde Park Avenue, Hyde Park MA 02136
Parents/guardians have the primary responsibility for the administration of medication to their children. The
administration of medication to students during the regular school hours and during school related activities is
discouraged unless necessary for the critical health and well-being of the student.
Protocol for Implementation
1. Medication Authorization Form – School personnel shall not administer to any student, nor shall any student
possess or consume any prescription or non-prescription medication except after filing complete medication authorization information. The school nurse reviews the written authorization and consults with the parent/guardian or physician for additional information as necessary. Authorization and any subsequent changes include: a. Physician’s written permission b. Student’s name, medication name, dosage, and date of order c. Administration instructions (route, time or intervals, duration of prescription) d. Reason/intended effects and possible side effects e. Parent/guardian written permission 2. Appropriate Containers – Medication and refills are to be provided in containers, which are:
a. Prescription labeled by a pharmacy or licensed prescriber displaying Rx number, student name, medication, dosage, and directions for administration, date and refill schedule and pharmacist name. b. Manufacturer labeled non-prescription over-the-counter medication. 3. Administration of Medication will be by the school nurse, or school administrator. Parents must provide
advance notice to the school nurse of field trips or other off campus activities. Other certificated school personnel may also volunteer to assist in medication administration and may be given instructions by the nurse. If no volunteer is available, the parent/guardian must make arrangements for administration. The school nurse or administration retains the discretion to deny requests for administration of medication. Prescription medications required for 10 days or less may be administered according to the directions on the original pharmacy medication label, in place of a written order. The nurse will not accept “as directed” on prescription labels. 4. Self-Administration – A student may self-administer medication at school and activities if so ordered by
his/her medical provider. Daily documentation will be provided as below (#6) for such health office supervised self-administration. For “as needed” medications such as those taken by students with asthma or allergies, the physician may also order that the student carry the medication on his or her person for his/her own discretionary use according to medical instructions when the student is off-campus for school related activities. However no daily documentation will be possible if this is the case. Self-administration privileges may be withdrawn if a student exhibits behavior indicating lack of personal responsibility toward self or others with regards to medication. 5. Storage and Record Keeping – Medication will be stored in the nurse’s office. Medication requiring
refrigeration will be stored in a secure area. Each dose will be recorded in the student’s individual health record. In the event a dose is not administered, the reason shall be entered in the record. Parents may be notified if indicated and it shall be entered in the record. To assist in safe monitoring of side effects and/or intended effects of the treatment with medication, faculty and staff may be informed regarding the medication plan. For long-term medication, written feedback may be provided at appropriate intervals or as requested by the licensed prescriber and/or parent/guardian. 6. Documentation, Changes, Renewals, and Other Responsibilities – To facilitate required documentation,
medical orders, changes in medical orders, and parent permissions may be faxed to the BPCPS School Nurse. It is the responsibility of the parent/guardian to be sure that all medication orders and permissions are brought to school, refills provided when needed, and to inform the nurse of any significant changes in the student’s health. Medication remaining at the end of the school year must be released to a parent/guardian or it will be discarded within one week. Every prescription order must be renewed each school year. Boston Preparatory Charter Public School 1286 Hyde Park Avenue, Hyde Park MA 02136 STUDENT EMERGENCY & HEALTH FORM

Student’s Name: _________________________________ Birthdate: ___ / ___ / ___
Current Grade: _____
Home Address: __________________________________________________
Phone Number: ___________________________
Name of Legal Guardian/Relationship: ___________________________________________________
Home #
Local persons to be notified in case of emergency or illness, when you are unable to be reached: 1) Name & Relationship: ________________________________________________ 2) Name & Relationship: ________________________________________________ 3) Name & Relationship: ________________________________________________
A) Allergies
a. Allergies to Medications: ___________________________________________________ b. Allergies to Food: ________________________________________________________ c. Is an Epi-Pen Required? _________________________ d. What is the treatment for your child’s allergic reaction? ___________________________ B) Illness/Chronic Condition (asthma, diabetes, G6PD, seizures, ADD, etc)
a. _____________________________________ b. _____________________________________ Boston Preparatory Charter Public School 1286 Hyde Park Avenue, Hyde Park MA 02136 C) Medications
Please list all prescription and over-the-counter medications your child takes. Include herbal treatments. Note: Prescription and over-the-counter medications that your child must take at school require an MD/NP order. Please see attached form. D) Vision
a. Glasses? _____ b. Contact Lenses? ____ E) Hearing
a. Hearing Problems? ____ b. Hearing Aids? ____ HEALTH CARE PROVIDER INFORMATION
Name of Doctor/Health Center: ________________________________________________________
Phone Number: _____________________________

Name of Health Insurance: _____________________________
Insurance #: ______________________________
Name of Dentist: ____________________________________________________________________
Phone Number: ___________________________

Confidential Information
I grant permission to the school nurse to share health information about my
child, on a need to know basis, with his/her teachers and coaches.

Medical Release
I understand that the Boston Preparatory Charter Public School has a responsibility to
my son/daughter to use responsible and prudent judgment in maintaining his/her health while engaged in the
school’s programs. With this in mind and in my absence: In the event of an injury or illness, I hereby give
Boston Preparatory Charter Public School 1286 Hyde Park Avenue, Hyde Park MA 02136
my permission for my son/daughter to receive medication and/or any other appropriate treatment (including
emergency surgery) by an area doctor, hospital or other appropriate medical facility.
Health Care Provider Release I grant the school nurse permission to exchange information with my
child’s health care provider. I understand that I can limit or revoke this consent at any time.
Yes___ No ___
Parent/Guardian Signature: _______________________________________ Date: ________

*Please bring this form into school or fax it to BPCPS at 617-333-6689.*


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