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Clinic

Clinic Forms

What we need from you to ensure a healthy and safe day for your student:

arrow  A Completely and accurately filled out Emergency Care Card.
arrowNote: We MAY NOT release your student to anyone who is not on the ECC.

arrow Please cooperate when you are asked to come in to sign for your child. This is a saety measure to protect you and your student.
arrow  Please contact me at 703-481-4072 if you have any questions or if your child has a health 
       condition that impacts his/her school day and would need a health plan.

arrow If your Student needs medications, we are required to stricly follow FCPS regulation 2102. (For more info see the opening packet and the FCPS website www.fcps.edu)

This includes:
arrowAppropriate Forms completely and correctly filled out and on file in the clinic. (center) Forms may be gotten at the clinic or downloaded at www.fcps.edu/forms

arrowMedication in a appropriately labeled orginal container

arrowAn adult must carry the medication in the clinic.

Authorization for Medication - www.fcps.edu/DIT/forms/se63.pdf

Authorization for Use of Inhaler - www.fcps.edu/DIT/forms/se65.pdf

Emergency Care Information for Students - www.fcps.edu/DIT/forms/se3.pdf

Emergency Care Prevention of Anaphylaxis Release and
Indemnification Agreement for Epinephrin
e - www.fcps.edu/DIT/forms/se64.pdf

School Entrance Health Form - www.fcps.edu/DIT/forms/mch213.pdf

Student Health Information - www.fcps.edu/DIT/forms/se71.pdf



Questions?   Find an error? Contact Curator: Stephanie Stewart, smstewart1@fcps.edu     Last updated: 29-Jan-2012

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