HEALTH HISTORY

Tylenol/Advil/OTC Medication

I give permission to the school nurse to share information relevant to my child’s health condition with appropriate school and/or emergency medical personnel when needed to meet my child’s health and safety needs. I give permission to exchange information with my child’s primary care physician for the purpose of referral, diagnosis and treatment. I give permission for emergency medical treatment.

According to the Department of Education, Department of Public Health and the Department of Early Education and Care regulations, all students are required to have a yearly physical exam and an updated immunization report on file.  A dental exam is strongly suggested.

Medication Requirements:

• If your child takes medication during the school day, and/or during residential hours, the following documentation is required to permit medication administration.
• A new written doctor’s order on physician’s letterhead for the 2021-2022 academic year.
• Written parental permission to administer medication. 
• An accurately labeled pharmacy container for medication(s).
• Medication  supply of not greater than a 1 month quantity, to be kept in the nursing department.
• Medications are to be delivered directly to the nursing department by a parent or adult, not the student. Medications will be administered by a nurse or her designee in the case of a field trip.

If your child has a special need regarding medication or medical treatment, delivery of a medication or a restriction, please call the Nursing Department at (508) 879-5110: 

For Middle and High School Students: Ext. 520 

For Pre-K and lower/upper Elementary School: Ext. 221 or 225

The nurse or their designee gives all medications. Written permission from parent/guardian and a physician’s order is needed for all medications and to allow for self-administration of medication.

I give permission to the school nurse, or personnel designated by the school nurse, to give prescribed medications listed above.

I give permission to the school nurse to share with appropriate school personnel information relative to the prescribed medicine as determined necessary for my child’s health and safety.

In a medical emergency, the parent/guardian and licensed prescriber will be notified.

Note: Parent/guardian may retrieve medication from the school at any time.  Medications not picked up within 1 week following termination of the order, or 1 week beyond the close of school, will be destroyed unless alternative plans have been made.

Medication Self-Administration Policy and Permission

Marie Philip and Walden School policy does not allow students to carry oral medication on their person or to self-administer medication. Exceptions may be made for students with asthma who carry an inhaler, for students who carry an Epi-pen or for students with other special needs.

The following documentation is required two weeks before the first day of school for self-administration:

1. A written doctor's order for the medication;
2. Written parent/guardian permission for the student to self-administer the specific medication;

In addition, the student must demonstrate the ability to follow the procedure for self-administration and be competent to keep a sufficient quantity of medication with them at school and on field trips or athletic events.

Field Trips

Physical Education and Athletics Programs 

Medical documentation of participant’s restrictions is required.

In order to be accepted onto a team and participate in practice and sports events, a student is required to have a current physical exam, less than one year old, that states he/she may participate fully in sports and specifies any limitations.

Photo/Video Release

Internet and Network Access Agreement

I understand and will abide by The Learning Center for the Deaf’s Internet Acceptable Use Policy as outlined in my Parent-Student Handbook. 

I understand that the primary purpose for my access privileges to TLC’s internet connection is for educational purposes and that my access should not interfere with my educational needs. 

I realize that the use of the internet at TLC is a privilege and not a right. I accept that inappropriate behavior on my part may lead to loss of access, disciplinary action, or other actions as determined by school administrators. 

I agree not to participate in the transfer of inappropriate or illegal materials through the school’s internet connection. I realize that, in some cases, the transfer of such material may result in legal action. 

I agree not to allow other individuals to use my account for internet activities, nor will I give my password or the password of anyone else, should I happen to know it.

The Audiology Clinic at The Learning Center for the Deaf is pleased to announce expanded audiologic services!  Our facility will now be able to provide hearing aid, cochlear implant, and earmold dispensing services to students who have MassHealth as either his/her primary or secondary insurance plan.  We will also be able to bill commercial insurances for the above services as well.

Note: Every insurance plan is different and coverage is dependent on the specifics of your and/or your child’s plan.   

CONFIDENTIALITY WAIVER and PARENTAL CONSENT

NOTE: Completion of this section by a parent/guardian authorizes the disclosure and/or use of your child’s individually identifiable health information consistent with the law (including HIPAA).

I understand that the school will protect this information as prescribed by the Family Educational Rights and Privacy Act (FERPA) and that the information becomes part of the student’s educational record. The information will be shared with individuals working at or with the school for the purpose of providing safe, appropriate, and least restrictive educational settings and school health services and programs.

Signing this authorization is required in order for my child to obtain audiologic dispensing services in the educational setting.

I give my permission for my child to undergo earmold and hearing aid impression/dispensing while at The Learning Center for the Deaf.  I authorize the educational and outpatient audiologists at The Learning Center for the Deaf to evaluate for necessary technology for my child and bill insurance as appropriate.  I certify that the information included on this form is accurate to the best of my knowledge. I understand and hereby release The Learning Center for the Deaf and its employees from any claims or liability connected with its reliance on this permission and agree to indemnify, defend, and hold them harmless from any claim or liability connected with such reliance.

Schools are required to annually report race and ethnicity data of students to the State/ Schools are asked by the Massachusetts Department of Elementary and Secondary Education to request parents/guardians or students to self-identify on the basis of race and ethnicity. However, this identification cannot be required of a parent, guardian, or student. Completion of this form is voluntary.