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MILLARD PUBLIC SCHOOLS
THIS SIDE MUST
BE REVIEWED YEARLY.
Student ________________________________________________ Male ___ Female ___ DOB ______________
Please list any Health Issues
that we should be aware of: ____________________________________
Medications taken at home: ______________________________________________________________________
Medications taken at school: _____________________________________________________________________
In case of an emergency or illness, list all numbers where you can be reached:
Mother’s Name Work Place/Hrs.
Father’s Name Work Place/Hrs. Wk. Phone # Cell Phone #
Legal Guardian’s Name Work Place/Hrs. Wk. Phone # Cell Phone #
(if legal custody has been set)
Birth/Adoptive Mother_______ Birth/Adoptive Father_______ Both______ Legal Guardian_______
In case of an emergency, and the above can’t be reached, I authorize the school district to contact and release
the student to the following persons in the order designated:
Daycare Provider: ________________________________________ Phone #_____________ Cell # ____________
Physician: ____________________________________________________ Phone #___________________
Dentist: ______________________________________________________ Phone #___________________
Life threatening health information will be shared with building staff members who work with
your student. If you do not want to have non-life threatening health information shared with staff
members, other than the principal and school nurse, please send written documentation to the
During normal school hours in life threatening situations, 911 will be called. If severe Asthma or Allergic
reaction occurs, 911 will be called, injected Epinephrine will be administered, followed by nebulized
Albuterol. Please inform the school nurse in writing if your student has a medical condition that would
require this not to be implemented.
Parent/Guardian Signature (Required)____________________________________ Date __________ If your child has ASTHMA or SEVERE ALLERGIES, please fill out backside of this form
MILLARD PUBLIC SCHOOLS
STUDENT ASTHMA/SEVERE ALLERGY INFORMATION
MANDATORY YEARLY UPDATE
COMPLETE THIS SIDE ONLY
IF YOUR CHILD HAS ASTHMA OR SEVERE ALLERGIES
Student ______________________________________________ Male ___ Female ___ DOB ________
Address __________________________________________________________ Phone _____________
Physician Treating Asthma: ________________________________________ Phone _______________
Current status of your child’s Asthma (Please check one) Mild ___ Moderate ____ Severe ____
Does your child use an “as needed” Inhaler?
If Yes, Inhaler Name ___________________________________________________________________
Does your child require any medication at school for Asthma?
Does your child use a Peak Flow Meter? Yes ____ No ____ Students Normal Peak Flow’s Green Zone: ________________ Action: _________________
Yellow Zone: ________________ Action: _________________
Red Zone: ________________ Action: _________________
Asthma Medication(s) taken: ____________________________________________________________
Please identify the things that trigger an asthma episode for your child: ___________________________
SEVERE ALLERGY INFORMATION
COMPLETE THIS ONLY IF YOUR STUDENT HAS SEVERE ALLERGIES
My child has a severe allergic reaction to the following: ______________________________________
Action taken for mild reaction: __________________________________________________________
Action taken for severe reaction: _________________________________________________________
Allergy medication(s) taken at home: ______________________________________________________
Allergy medication(s) taken at school: _____________________________________________________
Comments/Special Instructions: __________________________________________________________
Please submit medical Action Plan from physician if available
MC LEADERS TRAINING CREATING THE ENVIRONMENT FOR DISCIPLESHIP In the Story, we watch as Jesus makes disciples, turning fishermen into fishers of men. Then before he ascends into heaven, he gives them the mission to also make disciples who obey his commands And then over and over in Acts we see how they accomplished that mission. They did basically what Jesus did with his disciples. They pro
SLIPSTREAM Online Business Success Coaching Lesson 24 Massive List Building Technique EXPERT ONLINE SUCCESS COACHING 1 © Stuart Harris – Al rights reserved Foreword Welcome back to the SLIPSTREAM Membership program – lesson 24. Did you ever wonder if there was a more effective way to build a list.a very large list and very very quickly?Here is the answer you have been looking for.