Health and Student Forms

Call the front office to update any changes ASAP. In case of an accident or illness, and parents cannot be reached, the alternate emergency contact(s) shall assume responsibility for the child. If emergency contacts are unable to be reached, I hereby authorize Kuleana Education to refer my child to the physician/dentist listed below and/or take my child to the nearest medical facility for necessary treatment and/or medication at the parent/guardians’ expense.

Emergency Contacts

Asthma/RAD *

NO Asthma or RAD Mild Moderate Severe

Anaphylaxis *

NO YES

Asthma Triggers/Symptoms *

If YES to anaphylaxis, must fill out SEPARATE FORM from office.

Medication provided by school

Permission is given to Kuleana Staff to administer to my child the following over-the-counter medications below and given according to the student’s age and/or weight and not to exceed the manufacturer’s label. It is school policy students stay home until they are 24 hours free from a fever of 99 F and above without a fever reducer, diarrhea and vomiting before returning to school. Students with any contagious illness must be kept home until they have a doctor's note to return.

I agree to hold the Kuleana Education staff harmless in any or all claims arising from the administration of this
medication or the performance of this procedure at school.

I agree to notify the school of any change as necessary and renew yearly. The medication is to be given as needed and not on a daily basis. If your child needs them daily please take care of their needs at home. Students may carry cough drops or throat lozenges in their backpacks.

kuleana_health_record_form.pdf
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