* Please Note: According to Connecticut State requirements, the form should ideally be blue, so it can be found easily in a child's school health chart in the case of an emergency. It should be printed on blue paper or with any color printer (this may use a large amount of color ink to produce the blue background).Authorization for the Administration of Medicine by School Personnel
This form must be completed by a physician, nurse practitioner, physician's assistant, or advanced practice registered nurse for any medication your child might need in school. We have standing orders for Tylenol and emergency medication only. If your child needs anything else, including over the counter medication or Ibuprofen please have this form completed. Another reminder, a parent/guardian must sign the form and an adult must bring the medication into school labeled in the original pharmacy container.Physical Activity Restriction Form
This form is to be utilized when a student will be required to miss physical education for 2 weeks or more. It must be signed by a physician, nurse practitioner, physician assistant, or advanced practice registered nurse and the parent. Please remember that this form must be completed again each quarter that the student is restricted.Out of Town Emergency Form
Please fill this form out only when both parents are going out of town. One copy goes to the nurse and the second copy is for the temporary guardian. Remember that a child may only be released to: a person listed on the emergency card, named on this form, or someone you give us verbal authorization to release your child to. Even if a person lives in your home they may not take your child out of school if their name is not listed on one of the above forms.
For further information regarding health requirements and immunizations please refer to www.darienps.org/healthservices or call the Middlesex Health Room at 655-2518 and press 4 when the recording starts.
