Skip to main content

Medical Permission Form

Every Presbyterian Day School student must have emergency information on file with the school. The school is collecting the following online: Emergency Info, Permission to Treat, Allergy Info, School-Provided Over-the-Counter Medicine Permission.

Student Information

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Please choose grade level.

Use Existing Information

If you have no changes to the medical form you submitted previously, you can check the box below to have the nurse use the existing information:

This information includes:

  • immunization
  • allergies
  • medication information
  • medical restrictions
  • emergency contact information

Required Updated Information:

  • Immunization form for SK
  • Letter from physician for PE for 4th-6th Grades
  • Acknowledgment of Concussion and Sudden Cardiac Arrest Protocols for 4th-6th grades

If you have any questions about your existing medical data, please contact Alice Ball.

Invalid Input

You may need to scroll down to continue to the next section/submit button.

Immunization Requirements

PDS follows the Tennessee Department of Health Rules for Immunization. All students must have an up-to-date Tennessee Certificate of Immunization to attend school or a medical or religious exemption to vaccination form signed by the parents.

Note

The immunizations your son receives for Senior Kindergarten are the last ones he will have until he enters the 7th grade. If your son is re-enrolling for 1st-6th grade, you may ignore this section. The SK Certificate of Immunization is the last one you need to turn in while a student at PDS.

The state’s immunization schedule follows the current schedule published by the Centers for Disease Control and Prevention (CDC) and endorsed by the American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP).

This link provides all of the detail on immunization requirements.

Options

Please either upload a scanned copy of your son's immunization record, email it to the nurse, mail it to the school, or drop-off a copy at the school.

Instructions for Scanning : iOS | Android

If you have questions about immunization, please contact the school nurse:
Alice Ball, RN, BSN | | aball@pdsmemphis.org 901–842–4627

 

Invalid Input

 

Letter from Physician for PE

PDS also requires a written statement from your son’s physician stating that he can participate in physical education and all activities at school.

The nurse accepts any type of physical form (school, camp, generic). A simple note (cleared for all activities, PE & sports) signed by your son's doctor, or a checked box indicating "Date of Physical Exam" on your son's immunization form are also accepted. All forms/notes must be dated and be within a calendar year from the start of school.

If you have your letter, you may upload a scan below, otherwise please either email it to the nurse, mail it to the school, or drop it off with the Admission office.

 

Invalid Input

Allergies

Please list any food, drug or environmental allergies and indicate their severity and treatment.

Invalid Input
Invalid Input
If yes, please download and complete the Allergy Action Plan:
Allergy-Action-Plan.pdf
Popular 177.13 KB 		05/30/2020 10:21

All students with an epipen must have an Allergy Action Plan signed by their doctor on file with the nurse.

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Medical Issues, Restrictions

Please list any restrictions and acute or chronic medical conditions in the space provided below for your child. Examples include bee sting reactions, asthma, epilepsy/seizures, migraines, diabetes, heart condition, any organ condition, musculoskeletal condition, ADHD, and any other medical conditions that are important for the nurse to know.

Invalid Input
Invalid Input
Separate forms for additional over-the-counter medications that parents may bring to school or for prescription medications that students may take at school are located on the main forms page to print and bring with parent-supplied over-the-counter medications

School-Provided Over-the-Counter Permission

I give PDS permission to administer the following over-the-counter medications to my son as his condition indicates.

(Please check the medications that you want your son to receive):















Invalid Input
Invalid Input

Emergency and Medical Contact Information

While we will always contact parents first during an emergency, please list at least one non-parent, non-guardian emergency contact.

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Medical Emergency Treatment Consent

I hereby give my permission for Presbyterian Day School to obtain the services of any of the indicated physicians or hospitals in case the above named student suffers illness or accident. In the event that a parent, guardian, or emergency contact cannot be contacted, I authorize school officials to take whatever action is considered to be in the best interest of my child. (Please choose yes or no.)

Emergency Medical Consent is required.
Invalid Input
Invalid Input
Invalid Input

Concussion and Head Injuries

Public Chapter 148, effective January 1, 2014, requires that school and community organizations sponsoring youth athletic activities establish guidelines to inform and educate coaches, youth athletes and other adults involved in youth athletics about the nature, risk and symptoms of concussion/head injury.

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a “ding,” “getting your bell rung” or what seems to be a mild bump or blow to the head can be serious.

Did You Know?

  • Most concussions occur without loss of consciousness.
  • Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
  • Young children and teens are more likely to get a concussion and take longer to recover than adults.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?
Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed below after a bump, blow or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care provider (a Tennessee licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training) says s/he is symptom-free and it’s OK to return to play.

SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES
Appears dazed or stunned Headache or “pressure” in head
Is confused about assignment or position Nausea or vomiting
Forgets an instruction Balance problems or dizziness
Is unsure of game, score or opponent Double or blurry vision
Moves clumsily Sensitivity to light
Answers questions slowly Sensitivity to noise
Loses consciousness, even briefly Feeling sluggish, hazy, foggy or grogg
Shows mood, behavior or personality changes Concentration or memory problems
Can’t recall events prior to hit or fall Confusion
Can’t recall events after hit or fall Just not “feeling right” or “feeling down”

CONCUSSION DANGER SIGNS
In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention after a bump, blow or jolt to the head or body if s/he exhibits any of the following danger signs:

  • One pupil larger than the other
  • Is drowsy or cannot be awakened
  • A headache that not only does not diminish, but gets worse
  • Weakness, numbness or decreased coordination
  • Repeated vomiting or nausea
  • Slurred speech
  • Convulsions or seizures
  • Cannot recognize people or places
  • Becomes increasingly confused, restless or agitated
  • Has unusual behavior
  • Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT HIS OR HER SYMPTOMS?
If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brains. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?
If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care provider (a Tennessee licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training) says s/he is symptom-free and it’s OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration such as studying, working on the computer or playing video games may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

After reading the information about concussions, I am aware of the following information:

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Sudden Cardiac Arrest Education and Information

What is sudden cardiac arrest?
Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens, blood stops flowing to the brain and other vital organs. SCA doesn’t just happen to adults; it takes the lives of students, too. However, the causes of sudden cardiac arrest in students and adults can be different. A youth athlete’s SCA will likely result from an inherited condition, while an adult’s SCA may be caused by either inherited or lifestyle issues. SCA is NOT a heart attack. A heart attack may cause SCA, but they are not the same. A heart attack is caused by a blockage that stops the flow of blood to the heart. SCA is a malfunction in the heart’s electrical system, causing the heart to suddenly stop beating.

How common is sudden cardiac arrest in the United States?
SCA is the #1 cause of death for adults in this country. There are about 300,000 cardiac arrests outside hospitals each year. About 2,000 patients under 25 die of SCA each year. It is the #1 cause of death for student athletes.

Are there warning signs?
Although SCA happens unexpectedly, some people may have signs or symptoms, such as:

  • fainting or seizures during exercise;
  • unexplained shortness of breath;
  • dizziness;
  • extreme fatigue;
  • chest pains; or
  • racing heart.

These symptoms can be unclear in athletes, since people often confuse these warning signs with physical exhaustion. SCA can be prevented if the underlying causes can be diagnosed and treated.

What are the risks of practicing or playing after experiencing these symptoms?
There are risks associated with continuing to practice or play after experiencing these symptoms. When the heart stops, so does the blood that flows to the brain and other vital organs. Death or permanent brain damage can occur in just a few minutes. Most people who experience SCA die from it.

Public Chapter 325 – the Sudden Cardiac Arrest Prevention Act
The act is intended to keep youth athletes safe while practicing or playing. The requirements of the act are:

  • All youth athletes and their parents or guardians must read and sign this form. It must be returned to the school before participation in any athletic activity. A new form must be signed and returned each school year.
  • The immediate removal of any youth athlete who passes out or faints while participating in an athletic activity, or who exhibits any of the following symptoms:
    1. Unexplained shortness of breath;
    2. Chest pains;
    3. Dizziness
    4. Racing heart rate; or (v) Extreme fatigue; and
  • Establish as policy that a youth athlete who has been removed from play shall not return to the practice or competition during which the youth athlete experienced symptoms consistent with sudden cardiac arrest
  • Before returning to practice or play in an athletic activity, the athlete must be evaluated by a Tennessee licensed medical doctor or an osteopathic physician. Clearance to full or graduated return to practice or play must be in writing.
Invalid Input

Parent or Guardian Electronic Signature

My electronic signature signifies that the information provided in this document is accurate and that I have provided information, consent, authorization or agreement where indicated.

Sign Above
Invalid Input
Invalid Input

Everything Accurate?

Please double check all contact info is correct. If it is not please take this time to make changes.

Invalid Input
Please be patient after hitting submit. It may take up to 30 seconds to finalize.