Medication Information Form

For the 2023-24 School Year: This online form must be completed for all students attending The Summit School who are taking prescribed medication, whether at home or in school, or may need to receive emergency medication (EpiPen, inhaler, etc.). Please complete this online form before August 4. Having this information early in our planning is especially important. Thank you.

For children who must receive medication in school administered by our school nurse, you must also download and print our Medication Form [PDF] for your physician to complete, sign and return to the school nurse (contact info below) before August 18. A parent must also sign the Medication Form to provide permission to the school to follow their physician’s instructions. Medication can only be administered at school with signed instructions.

Asterisk (*) indicates a required form field. An email-based reference copy of the form information will be sent to the person submitting the form once processed by Summit’s administrative team. If more than one child attends Summit, a separate form must be completed for each child.

Upper School:
Lucy Ware, RN
School Nurse
The Summit School
187-30 Grand Central Parkway
Jamaica Estates, NY 11432
Telephone 718-264-2931 x217
Email lware@summitqueens.com

Lower School:
Marisa Tanzi, LPN
School Nurse
The Summit School
183-02 Union Turnpike
Flushing, NY 11366
Telephone 718-969-3944, Ext. 318
Email mtanzi@summitqueens.com

    STUDENT INFORMATION

    Student Name *

    First Name

     

    Last Name

    Date of Birth *

    MM

    DD

    YYYY

    Age *

    My Child Attends Summit's

    Lower SchoolUpper School

    PRESCRIPTION MEDICATION

    List all daily medication, whether taken at home or at school.

    Drug 1 Name

    Drug 1 Dose

    Drug 1 Administer At School

    YesNo

    Drug 1 Physician Name

    First Name

     

    Last Name

    Drug 1 Physician Telephone

    (###)

    ###

    ####

    Drug 2 Name

    Drug 2 Dose

    Drug 2 Administer At School

    YesNo

    Drug 2 Physician Name

    First Name

     

    Last Name

    Drug 2 Physician Telephone

    (###)

    ###

    ####

    Drug 3 Name

    Drug 3 Dose

    Drug 3 Administer At School

    YesNo

    Drug 3 Physician Name

    First Name

     

    Last Name

    Drug 3 Physician Telephone

    (###)

    ###

    ####

    Drug 4 Name

    Drug 4 Dose

    Drug 4 Administer At School

    YesNo

    Drug 4 Physician Name

    First Name

     

    Last Name

    Drug 4 Physician Telephone

    (###)

    ###

    ####

    PRESCRIBED EMERGENCY MEDICAL CONDITIONS

    Select all emergency medication needs and treatments. A separate action plan will be required for each condition at a later date.

    ASTHMA

    YesNoTreatment: InhalerTreatment: Nebulizer

    DIABETES

    YesNoTreatment: Insulin

    SEVERE ALLERGIES

    YesNoTreatment: EpiPenTreatment: Benadryl

    Add Type of Allergy/Specifics

    Example: Food: Peanuts; Insect: Bees; Drug: Amoxicillin; Other: Milk, Dust

    SEIZURE DISORDER

    YesNo

    Please Add Any Treatment Information

    SUBMITTED BY

    Thank you for providing the information requested above, which will be especially helpful in our planning prior to school starting. If you indicated that any medication should be administered at school (daily or emergency), please remember to provide a copy of our Medication Form to your physician to complete, sign, and return to The Summit School.

    Parent Name

    First Name

     

    Last Name

    Parent Email

    OUR MISSION

    We provide children who have learning and emotional challenges, the educational support they require to achieve typical academic milestones and develop their individual strengths and talents. Our mission is to help our students maximize their strengths, develop self-esteem, become productive contributors to society, and go on to pursue higher education, careers, and interpersonal relationships.

    CONTACT US

    UPPER SCHOOL
    address: 187-30 Grand Central Parkway
    Jamaica Estates, NY 11432
    phone: 718-264-2931

    LOWER SCHOOL
    address: 183-02 Union Turnpike
    Flushing, NY 11366
    phone: 718-969-3944

    © 2024 The Summit School. All Rights Reserved.

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