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OCDSB 802 Serious Medical Conditions Protocol FULL VSNOCDSB 802 School Operations (June 2014) Confidential When Complete Page 1 of 2 Distribution OSR NOTE: Please type or print neatly and submit the original, signed copy to your child’s school principal in a timely manner. This authorization will terminate either on August 31 of each school year or upon notice of when the prescription changes or expires. School Name: Date: Principal’s Name: Teacher’s Name: Student’s Name: Student No. : Year/Grade Pick-up and Drop-off Bus Route Numbers (if applicable): Transportation Address: STUDENT PHOTO: PLEASE ATTACH A RECENT PHOTO OF STUDENT TO FORM MEDICAL CONDITION Epilepsy Heart Condition Pace Maker Asthma Other (specify): SYMPTOMS AND WARNING SIGNS (To be completed by parent/guardian): _____ ______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ COURSE OF ACTION (To be completed by parent/guardian): _____ ______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ MEDICATION TO BE ADMINISTERED (if required): (Administration of Oral Medication Authorization OCDSB 286 and/or Self-Administration of Oral Medication Authorization OCDSB 285 must be completed, signed and on file with the school principal.) _____ ______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ CALL PARENTS/ GUARDIANS: Parent/Guardian: Telephone (Home): Alternate Telephone Number: Serious Medical Conditions Protocol Registration (References: P.108.SCO and PR.548.SCO ) OCDSB 802 School Operations (June 2014) Confidential When Complete Page 2 of 2 Distribution OSR OR Parent/Guardian: Telephone (Home): Alternate Telephone Number: Principal shall decide if an ambulance is to be called. Parent/Guardian Signature (or student if 18 years or older): Date: The personal information on this form is collected under the authority of the Education Act and will only be used to record parental authorization for the administration of the named medication to the student by Board staff. Access to this information will be limited to those who have an administrative need, to the student to whom the information relates, and the parent(s)/guardian(s) of a student who is under 18 years of age. If you wish to review this information, please contact the school Principal.