Lenape Valley Regional High School

P. O. BOX 578, STANHOPE, NJ 07874

Health Office

Dear Parent/Guardian:

Welcome to a new school year at Lenape Valley Regional High School. Please review this

medical information carefully prior to the start of school in September 2016. Keep this letter for

future reference.

Medications in School

The school medication policy and information about the forms that you are to use is included in

this letter. The certified school nurse or the parent/guardian are the only people permitted to

administer medication in school. Be advised that faxed permissions and telephone

permissions are not accepted. Only hard copy Lenape Valley Regional High School

medication forms will be accepted.

Medication Administration Forms

I. Prescription medication and/or self-administered medication

A. School Administration

School Administration of prescription medication, requires written consent of both

parent/guardian AND physician. This form is also needed for medications required on

overnight field trips.

B. Self-Administration

A pupil may be permitted to self-administer medication for asthma or other potentially

life threatening illnesses. Written consent of both parent/guardian AND physician is

required.

Bee Sting and other Allergic Reactions

The section of the prescription medication form for EpiPen use is for parents to complete

for students known to have an allergic reaction to bee stings, food and other designated

allergies in order for the school nurse to provide these children with the necessary

immediate care.

A nebulizer is available in the health office; however, parents must provide the

medication and a doctor’s order to allow students to use it when needed.

Parents of students with asthma are requested to visit the Pediatric/Adult Asthma

Coalition of New Jersey web site at www.pacnj.org. From there, please download the

Asthma Treatment Plan, fill it in and return it to the school nurse.

II. Non-prescription medication

School administration of non-prescription medication requires parent/guardian written

consent for the following medications: Advil, Tylenol, Sudafed and Maalox. Any other

non-prescription medications such as Benadryl, Motrin, Excedrin, etc. require both

parent/guardian and physician written consent.

Medication Policy

All prescription and non-prescription medications must be brought to and from school by a

parent/guardian or a responsible adult with the written permission. Prescription medication must

be in the original pharmacy container with an intact prescription label. Non-prescription

medication (such as Benadryl, Motrin, etc.) must be in the original container. Permission for

prescription and non-prescription is effective for one school year only.

Scoliosis Screening

The state requires that students are screened for scoliosis bi-annually. Scoliosis is a

musculoskeletal disorder in which there is a sideways curvature of the spine, or backbone. A

form giving permission for this screening is included. Please fill out the top of the form and

indicate your permission or refusal with the appropriate signature. Please return this form to the

health office the beginning of the school year.

Elevator Keys

Elevator keys are loaned to students requiring use of the elevator when authorized by a

physician. A deposit of $5.00 is required which is refunded to the student when the key is

returned to the health office. A physician’s note indicating the need to use the elevator and time

frame required must be brought to the health office to obtain a key.

Medical Excuses from Physical Education

Successful student participation in Physical Education is both a state and local requirement for

high school graduation. Students can be medically excused from participation if they have a

valid gym excuse signed by a physician and presented to the school nurse the first day of the

excused absence.

A physician’s certificate that states a student is excused from gym “until further notice”

must be updated periodically. If no specific date for return is indicated, the excuse must be

renewed or cleared by the physician four weeks after the date on which the certificate was

issued.

Please be sure as parents, that you monitor such excuses carefully. Failure to return to active

participation on time can jeopardize a student’s grade in physical education and possible

graduation

If you have any questions regarding the administration of prescription and non-prescription

medications or other health concerns, please contact the school health office. If you experience

problems downloading / printing the required forms, contact me via phone or e-mail and I will

send you copies.

Thank you for your cooperation.

Sincerely,

Ruth Kelley, RN, BSN

School Nurse

973-347-7600 Ext: 5116

rkelley@lvhs.org

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LENAPE VALLEY REGIONAL HIGH SCHOOL P.O. BOX 578, STANHOPE, NJ 07874

(973) 347-7600

PARENTAL AND PHYSICIAN’S AUTHORIZATION FOR ADMINISTERING MEDICINES TO STUDENTS

DO NOT RETURN THIS FORM UNLESS YOUR CHILD IS TO RECEIVE

MEDICATION, EPIPEN, OR INHALER AT SCHOOL. All medication orders must be

renewed each school year. THIS FORM COVERS THE 2016 – 2017 SCHOOL YEAR.

A. To be completed by the Parent / Guardian:

I request that my son / daughter _______________________________ in grade _____ receive the medication as

prescribed below by our physician. The medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand that the school nurse will administer the medication unless otherwise

indicated by the physician below.

Please discuss the following with your doctor:

My child will require medication on half days ___ yes ___ no

My child will require medication on field trips ___ yes ___ no

I agree that the Lenape Valley Regional High School district shall incur no liability as a result of an injury

arising from self-medication. I further state that the district will be held harmless against any injury or

claims as a result of pupil’s self-medication. I further relieve the board and its employees of liability for

administration of this prescription medication.

____________________________________________ _____________ (____) ____________________________

Signature of parent / guardian Date Day time telephone number

B. To be completed by the Physician:

I request that my patient, as listed below, receive the following medication:

Name of pupil _________________________________________________________________ Age ___________

Diagnosis _____________________________________________________________________________________

Name of medication ____________________________________________________________________________

Prescribed dosage and means of administering _______________________________________________________

_____________________________________________________________________________________________

Time to be taken during school hours _______________________________________________________________

Expected duration of treatment ____________________________________________________________________

Possible side effects and adverse reactions (if any) ____________________________________________________

_____________________________________________________________________________________________

Epipen / Inhaler (Initial accordingly):

_____ The above mentioned student will carry and use his/her own inhaler as indicated above.

_____ The above mentioned student will carry and use his/her own epipen as indicated above.

_____ School nurse will administer inhaler / epipen. _____ Nurse must administer on field trips

Other recommendations _________________________________________________________________________

_____________________________________________________________________________________________

Physician Name (please print) __________________________________ Phone (___) ________________________

Physician Signature _________________________________________ Date ______________________________

LENAPE VALLEY REGIONAL HIGH SCHOOL P.O. BOX 578, STANHOPE, NJ 07874

(973) 347-7600

PARENTAL PERMISSION FOR SCOLIOSIS SCREENING

2016 – 2017 SCHOOL YEAR

Student Name _________________________________ Grade _________ Please check YES or NO for the following statement:

____ ____ I give permission for scoliosis screening in the health office for my child. YES NO Signature of parent / guardian _______________________________ Date _________ Printed name of parent / guardian __________________________________________

LENAPE VALLEY REGIONAL HIGH SCHOOL P.O. BOX 578, STANHOPE, NJ 07874

(973) 347-7600

SCHOOL ADMINISTRATION OF NON-PRESCRIPTION MEDICATION

The Lenape Valley Regional High School district requires that parent / guardian provides written request for the school nurse to dispense non-prescription medications

approved by the school doctor. Permission is effective for one (1) school year and must be renewed annually. THIS FORM COVERS THE 2016 – 2017 SCHOOL YEAR.

TO BE COMPLETED BY PARENT/GUARDIAN

I request that my son / daughter _________________________________ / _________ Name Grade be given Advil Tylenol Sudafed Maalox non-prescription medication for ----------Please circle medication---------- ______________________________________________.

Condition requiring medication. I relieve the board and its employees of liability for administration of this non-prescription medication.

___________________________________ __________________ Signature of Parent / Guardian Date (_____) _________________________ Day time telephone number Only the following non-prescription medications are approved by the school doctor to be dispensed with appropriate parental permission: Brand Name Generic Advil ibuprofen Tylenol acetaminophen Sudafed pseudoephedrine hydrochloride Maalox antacid tablets