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OCDSB 802 School Operations (June 2014) Confidential When Complete <br />Page 1 of 2 <br />Distribution OSR <br />NOTE: Please type or print neatly and submit the original, signed copy to your child’s school <br />principal in a timely manner. This authorization will terminate either on June 30 of each school <br />year or upon notice of when the prescription changes or expires. <br />School Name: Date: <br />Principal’s Name: Teacher’s Name: <br />Student’s Name: Student No. : <br />Year/Grade <br />Pick-up and Drop-off Bus Route Numbers (if applicable): <br />Transportation Address: <br />STUDENT PHOTO: PLEASE ATTACH A RECENT PHOTO OF STUDENT TO FORM <br />MEDICAL CONDITION <br />Epilepsy Heart Condition Pace Maker Asthma <br />Other (specify): <br />SYMPTOMS AND WARNING SIGNS (To be completed by parent/guardian): <br />_____ ______________________________________________________________________ <br />________________________________________________________________________________ <br />________________________________________________________________________________ <br />COURSE OF ACTION (To be completed by parent/guardian): <br />_____ ______________________________________________________________________ <br />________________________________________________________________________________ <br />________________________________________________________________________________ <br />MEDICATION TO BE ADMINISTERED (if required): <br />(Administration of Oral Medication Authorization OCDSB 286 and/or Self-Administration of Oral <br />Medication Authorization OCDSB 285 must be completed, signed and on file with the school <br />principal.) <br />_____ ______________________________________________________________________ <br />________________________________________________________________________________ <br />________________________________________________________________________________ <br />CALL PARENTS/ GUARDIANS: <br />Parent/Guardian: <br />Telephone (Home): <br />Alternate Telephone Number: <br />Serious Medical Conditions <br />Protocol Registration <br />(References: P.108.SCO and PR.548.SCO )