RSSP Student Information & Medical/Emergency Form
Intake Meeting Date:______________________
Student’s Name_____________________________ Home School_____________________________ Address_____________________________________ City, Zip____________________ __________ Current Age_____ Birthdate___/____/______ Gender: M F Ethnic Origin_________________ Guardian______________________________ Relationship to Student__________________________ Address__________________________________________ City, Zip___________________________ Home Phone_________________ Work Phone_________________ Cell Phone___________________ Guardian______________________________ Relationship to Student__________________________ Address_________________________________________ City, Zip_____________________________ Home Phone__________________ Work Phone_________________ Cell Phone__________________ TWO ADDITIONAL EMERGENCY CONTACTS REQUIRED:
1. _____________________________________relationship_______________
Address__________________________________________________________
Home Phone__________________ Cell/Work Phone_____________________
2. _____________________________________ relationship_______________
Home Phone___________________ Cell/Work Phone____________________
Does the parent/guardian support the student’s enrollment to the RSSP? YES NO Current Grade Placement: 6 7 8 9 10 11 12 Is student currently on probation or under court supervision? YES NO
If “yes”, please indicate name of probation officer:_____________________________________
Is student currently involved with a truancy officer? YES NO
If “yes”, please indicate name of officer:_____________________________________________
Is student involved with any social service agency (DCFS, DHS, YSB, etc.)? YES NO If so, please explain.
ADDITIONAL EMERGENCY MEDICAL INFORMATION FOR ________________ This form has been developed to be in compliance to provide medical information pursuant to HB 5939. When this form is completed it will be placed in a student temporary file in the event of a student health emergency. ADDITIONAL CONTACT INFORMATION
State law mandates that students not be released during emergency/disaster situations to any person not listed in writing. Please list additional persons you would authorize to transport your child in an emergency. Name_____________________Address____________________Phone______________ Name_____________________Address____________________Phone______________ Name_____________________Address____________________Phone______________ Name_____________________Address____________________Phone______________ Known Medical Conditions__________________________________________________ Current Medications or Chronic Illness________________________________________ _______________________________________________________________________ If medication must be administered during school day, please list the following: Medication _______________________Dosage_________________Time____________ Medication _______________________Dosage_________________Time____________ Known Allergies__________________________________________________________ Possible Symptoms/Allergies________________________________________________ My child may________or may not________have Tylenol during the school day. My child may________or may not________have Ibuprofen during the school day. My child may________or may not________have cough drops during the school day. Doctor___________________Address______________________Phone_____________ I, _______________________________________________, confirm that I am primarily responsible for
administering medication to my child. However, in the event that I am unable to do so or in the event of a medical
emergency, I hereby authorize Marshall/Putnam/Woodford Regional Safe School Program and its employees and
agents, in the behalf and stead, to administer or to attempt to administer to my child (or allow my child to self-administer, while under the supervision of the employees and agents of the school district), lawfully prescribed
medication in the manner as listed on the medication container or so specified in writing by me. I acknowledge that the administration of medication to my child will be performed by an individual other than a school nurse, and I specifically consent to those practices.
I further acknowledge and agree that, when the lawfully prescribed medication is so administered or
attempt to be administered, I waive any claims I might have against the Regional Safe School Program, its employees and agents arising out of the administration of said medication. In addition, I agree to hold harmless
and indemnify the Regional Safe School Program, its employees and its agents, either jointly or severally, from and
against all claims, damages, causes of action, or injuries incurred or resulting from the administration or attempts
I authorize the RSSP to secure emergency medical care or transportation when I, or my designated
medical contacts cannot be immediately reached and it’s determined that immediate action is required. If time allows for a preference, please use _________________________Hospital.
_____________________________/____________________________/_____________ Parent/Guardian signature
_____________________________/____________________________/_____________ Parent/Guardian signature
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Multi-analyte assay of 23 Anti Epileptic Drugs (AEDs) in human plasma Renata Lagewaard, Ronald Vermunt, Toos de Mooy, Jos vd Elshout, Robert vd Wegen, Robert Wortelboer and Rudi Segers Introduction Until the early 1990s, the choice of antiepileptic medication was limited to traditional drugs such as phenobarbital, primidone, phenytoin, carbamazepine and valproate. Although th