Enrollment Forms
- Medication Administration Plan
- Authorization to Release Records
- Student Registration Residency Affidavit
Medication Administration Plan
Dear Parent/Guardian,
We would like to inform you of the medication administration policies that have been put in place to ensure the health and safety of students needing medications during the school day.
Our school district requires that the following TWO forms must be on file in your student’s health record before we begin to give any medicine at school:
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Signed medication order by licensed provider. A completed written medication order from your student’s licensed provider. This order must be renewed as needed and at the beginning of each academic year.
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Signed consent by the parent or guardian to give the medication. Please complete the enclosed HPS Medication Administration Plan and give it to your school nurse.
Prescription medications should be delivered to the school nurse in a labeled pharmacy container by a parent or guardian. Non-prescription medication should be delivered to the school nurse in an unopened manufacturer-labeled container by a parent or guardian.
No more than a thirty-day supply of the medicine should be delivered to the school. You may also visit the district website for further information regarding medication administration: https://www.holliston.k12.ma.us/district-departments/health-office
Thank you for your prompt cooperation in this matter.
Sincerely,
Holliston Public School Nurses
Health Services Department
Sam Placentino School Fred W. Miller School Robert Adams Middle School High School
235 Woodland Street 235 Woodland Street 323 Woodland Street 370 Hollis Street
Holliston, MA 01746 Holliston, MA 01746 Holliston, MA 01746 Holliston, MA 01746
P (508) 429-0647 P (508) 429-0667 P (508) 429-0657 P (508) 429-0677
F (508) 429-0699 F (508) 429-0690 F (508) 893-6053
Medication Administration Plan
Student: ________________________________________________________ DOB: _______________
School: _______________________________________________________Grade: _______________
Name of Lic. Prescriber: _____________________________________________________________
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Parent/Guardian Name: _________________________________________________________________ Cell Phone: ______________________________________________________________________________
Parent/Guardian Name: ________________________________________________________________
Cell Phone: ______________________________________________________________________________
Emergency Contact (other)______________________________________________________________ |
Diagnosis: ________________________________________________________________________________________________________________________________________________________________________
Allergy (if applicable): ____________________________________________________________________________________________________________________________________________________________
Name of Medication: _____________________________________________________________________________________________________________________________________________________________
Specific Directions (e.g., times to be given): _____________________________________________________________________________________________________________________________________
Back-up Plans (e.g., school nurse unavailable): ❏ Call 911/EMS ❏Other: ___________________________________________________________________________________________________
Plan for Field Trip: ❏ Sent on Field Trip and administered by designated school personnel ❏Other__________________________________________________________________________
Other persons to be notified of diagnosis and medication: ❏ Appropriate school personnel necessary for student health and safety, including bus drivers
❏ Other: ________________________________________________________________________________________________
Plan for medication monitoring (e.g., temperature control): ❏ Not applicable ❏Other: ______________________________________________________________________________________
Plan for teaching self-carry/administration (as appropriate) applicable only for prescription inhalers, epinephrine auto-injectors, insulin delivery systems, and enzyme supplements: ❏ No ❏ Yes (MUST complete second page)
Storage Location of medication (check all that apply): ❏ Health Office ❏ Self-carry
*I give permission for the above medication to be administered as prescribed to my student. Non-medical staff can only administer epinephrine auto-injectors if trained.
*I understand medication will be destroyed if not picked-up by the expiration date or the last day of school.
Parent/Guardian Signature _______________________________________ Date________________
*Medication order MUST be included with this form*
*ONLY COMPLETE THIS SECTION FOR SELF CARRY/ADMINISTRATION*
Self carry/administration will be allowed only when the criteria of the Self Administration Medication Plan have been met. The plan is effective only for the same school year it is granted and must be renewed each year.
Parent/Guardian Consent of Administration
I, the parent/guardian of _______________________________________________________________________, give permission for my student to self-administer the above listed medication.
Parent/Guardian Name (printed): ___________________________________________________________________________________________________________________________________________________
Parent/Guardian Signature ____________________________________________________________________________________________________________________ Date________________________________
Student Consent of Administration
Responsibilities:
1. Student demonstrates knowledge of the medication and when it should be used ❏ Yes ❏ No
2. Student informs the nurse if there are any issues with self administration ❏ Yes ❏ No
Student Name (printed): ____________________________________________________________________________________________________________
Student Signature_____________________________________________________________________________________Date_________________________
School Nurse Consent to Student Medication Self Administration Plan
Self-administration of medication in the school setting will be allowed if the following are met:
- A valid medication order and treatment plan from a licensed prescriber has been received.
- The student’s parent/guardian has completed and submitted to the school any written documentation required by the school.
- The school nurse has developed a Medication Administration Plan (MAP) which contains only those elements necessary to ensure safe self-administration of medication.
- The minor student’s parent/guardian has signed the Consent of Administration.
- The student has demonstrated to the school nurse the skill level necessary to use the medication and any device necessary to administer such medication prescribed and has reviewed and signed the Consent of Administration.
- The school nurse has determined it is safe and appropriate for the student to self administer the prescribed medication and has signed the Consent for Self Administration
- The signed consent for self administration in the school setting will be kept with the student’s medication orders in their medical file.
School Nurse Name (printed): ____________________________________________________________________________________________________________
School Nurse Signature ____________________________________________________________________________________Date_________________________
Medication Verification Chart
Date | Medication | Dose | Quantity | Nurse Signature | Parent/Guardian Signature |
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Authorization to Release Records
Office of the Superintendent
370 Hollis Street • Holliston, Massachusetts 01746
Telephone (508) 429-0654 • FAX (508) 429-065
Susan E. Kustka, Ed.D. Joanne Menard, Ed.D.
Superintendent of Schools Assistant Superintendent
Authorization to Release Information
Name of Student: Grade
Please forward cumulative, psychological, medical, special needs and discipline files to be released on the above named student to the school checked below.
Holliston High School School Counseling Department 370 Hollis Street Holliston, MA 01746 Contact: Valerie Camiel |
Phone 508-429-0677 Fax 508-893-6053
508-429-0677 x1107 |
Robert H. Adams Middle School Guidance Department 323 Woodland Street Holliston, MA 01746 Contact: Lisa Ahronian |
Phone 508-429-0657 Fax 508-429-0690
508-429-0657 x1402 |
Fred W. Miller Elementary School 325 Woodland Street Holliston, MA 01746 Contact: Shannon Carbino |
Phone 508-429-0667 Fax 508-429-0699
508-429-0667 x1324 |
Sam Placentino Elementary School 323 Woodland Street Holliston, MA 01746 Contact: Maureen Ohnemus |
Phone 508-429-0647 Fax 508-429-0691
508-429-0647 x1202 |
Last School Attended
Name of School: ____________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Phone: Fax:
Parent/Guardian Signature Date
Student Registration Residency Affidavit
Click here to download this form in a PDF
STUDENT REGISTRATION
RESIDENCY AFFIDAVIT
Any applicant for the Holliston Public Schools who cannot produce required residency documents in their own name must ask the owner or lessee of the property where the applicant lives to complete Section1, sign and have this affidavit notarized. The following three documents are required:
1. A current mortgage, tax bill or lease; and
2. A recent utility bill (cable, satellite, electric, gas, water, home/renter insurance) and
3. A valid photo identification
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SECTION I |
To be completed by the owner, lessee or landlord |
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I, , am the homeowner/lessee/landlord of the property located at PRINT NAME in the Town of Holliston. ADDRESS
who is the parent or legal guardian of , is living PRINT NAME PRINT STUDENT NAME
at this address as their principal residence.
I understand that the information contained in this legal affidavit is subject to verification at any time. Signed under the pains and penalties of perjury this day of of 20 . _____________________________________________________________ ________________________________ Signature of Homeowner / Tenant / Landlord Phone Number |
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SECTION II |
To be completed by parent or guardian |
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To attend the Holliston Public schools, a student must actually reside in the Town of Holliston. The residence of a minor child is presumed to be the primary legal residence of the parent/guardian who has physical custody of the child. “Residence” is the place where a person dwells permanently, not temporarily, and is the place that is the center of his/her domestic, social and civic life. Temporary residence in the Town of Holliston solely for the purpose of attending Holliston Public Schools will not be considered residency. Any student who is found not to reside in the Town of Holliston will be dismissed from the Holliston Public Schools. Additional penalties – including fines and legal action – may be imposed on families found to be in violation of the residency policy. This residency policy does not apply to homeless students. I understand that the information contained in this legal affidavit is subject to verification at any time. Signature of parent/guardian_____________________________________________________________________________________ |
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Signature of Public Notary_________________________________________________________________________________________
Sworn to before me this day of of 20 .