Please click the links below to view/download forms:

Permission to administer

Permission for the Administration of Medications and/or Treatments

Orders for gtube

Physician/Hospital/Click Orders for Gastrostomy Tube/Button Feed

Physicians medical report

Physician Medical Report and Parent/Guardian Release Form

Return to program

Return to Program Form

Fairhaven Nursing

420 Lincoln Way, Niles, OH 44446 | Phone: (330) 652-5811 ext. 724 | Fax: (330) 574-4517

Lynnette DeChellis, RN

Regina Poullas, RN

Tami Lewis, RN


Fairhaven Clinic

Below you will find necessary forms and policies for medication administration, ER/ hospital visits, physical and immunization requirements and health updates.

In the clinic we are only permitted to give medications/ tube feedings with a doctor’s order. This includes over the counter as well as prescription medications. It also includes orders for thickeners, treatments and nutritional support drinks. We require new medication/tube feeding orders for each school year. These orders must be signed and dated by both the physician and the parent/guardian.  Orders should only be obtained for those medications given during school hours. A medication that is given once or twice per day should be given at home unless ordered for a time during school hours.

Must specify milligram dosage not just 1 pill, one puff, etc.
Must specify time and route to be given.
Must have allergies listed.
Must be signed by physician and parent/guardian.
If ordered “as needed” must give time or frequency.
It is the parent/ guardians’ responsibility to obtain doctor’s orders.

Must be sent in as ordered. If ½ tablet is ordered, then the tablet must be cut in half before sending.
Must be sent in the original box. When sending over the counter medication, it must have the child’s entire name written on the box.
Prescription medications must be sent with a pharmacy label that exactly matches the doctor’s order. This includes inhalers. They must be sent in the original pharmacy box with a label.
Medications must be brought in by the parent. No medication can be sent in on the bus or in a child’s backpack.Your Content Goes Here

All tube feedings must have a doctor’s order that specifies the amount to be given, rate and time of feeding along with any special instructions. Thickeners must have doctor’s orders that give clear instructions on how they are to be mixed. Nutritional support drinks should have a doctor’s order stating how much should be given during the school day. All feedings/ feeding supplies and support drinks can be transported by busing.

Orders for gtube
Drs order form

Yearly physicals are encouraged for children in all grades. A physical form can be requested from the nurses office at any time. Any physical form from the doctor can be used as well as long as it is dated and signed by the doctor.

All children entering into preschool must have a current physical. Yearly physicals are mandatory for preschool and are monitored by the state. If your child’s physical is close to expiring, you will be sent a notice before it expires. You will have 30 days after the date it expires to obtain a new one. Your child must have a current physical on file in order to attend.

On the back of the Fairhaven physical is an order for swimming. We must have a  yearly doctor’s consent for your child to swim if your child has a seizure condition, an aspiration/ swallowing disorder, or a gastrostomy tube in place.

Physical Form

All students are required to submit an immunization record before starting school at Fairhaven.

If your child is missing any immunizations, you will have a 14- day grace period in which to obtain these shots. If, for a medical reason the immunization cannot be given, parents must sign a yearly exemption form. See below for required immunizations for Pre- school, Kindergarten, 7th and 12th grade.

Immunization form

During the school year, if you take your child to the emergency room or if your child is admitted to the hospital, we will need a return to program form from the emergency room, the hospital or your physician. It does not have to be written on the Fairhaven form but must include the date they are allowed to return to school and any restrictions your child may have (Ex. No swim for 2 weeks) We must also have a return to program if we send your child home with something that could possibly be contagious.

return to program form

In order for us to best protect your child, on our emergency form there is a space for allergies listed. Please write anything your child may be allergic to; especially any food items. You may receive a call from Nursing to discuss your child’s allergies. If your child has an allergy severe enough for an Epipen or other antihistamine, you will be asked to fill out and sign an Allergy Action Plan. This will be distributed to the teacher, gym/swim, the lunchroom, if necessary and transportation in case of a severe allergic reaction.

Allergy Action Plan

On the back of the Fairhaven Emergency form at the bottom is a place to fill out if your child has ever had a seizure. This is important information for Nursing to know in order to better care for your child. Please fill in the appropriate boxes and if possible, give a detailed description of any seizure activity your child has had including febrile seizures. You may receive a call from Nursing asking for more details. If your child is on a current seizure med or has a rescue medication for seizures, we are asking that you fill out a seizure action plan. This will be shared with the classroom, gym/swim, and transportation in order to have a plan of care for your child.

Seizure Action plan

Any student that uses a rescue inhaler for periodic episodes of asthma at home must also have one for school use. This is a school policy if your child has a diagnosis of asthma. We ask that all inhalers be brought in with a spacer. If your child uses a nebulizer treatment for their asthma, the tubing, mask and medication must be sent in. We have nebulizers for use in the clinic. If you have an Asthma Action plan from Akron Children’s Hospital, we ask that you send that in as well. We also ask that you fill out our own Asthma Action plan that will be shared with the classroom, gym/swim and busing. This will help us to be aware of triggers and allow our Fairhaven staff to better care for your child.

Asthma Action Plan

The clinic at Fairhaven wants to insure the health and wellness of your children. While at Fairhaven, in addition to regular gym and swim, your child will have the opportunity to take part in Friday Fitness. This allows school age children to walk to music each Friday. Our new playgrounds are used often and physical fitness is encouraged. We also have the Dental Van that comes yearly and parents are encouraged to have their children seen by the dentist. We want to do all we can to keep your children well.

The Fairhaven Clinic would like to give you some guidelines as to when your child should not come to school.

Appearance/ Behavior: If your child is pale, unusually tired or has no appetite, your child may be coming down with something and should be kept at home to be monitored.

Eyes: If your child has any redness, burning, itching or drainage from the eyes, this may be a sign of “pink eye” which is contagious. Your child should remain at home and should be evaluated by your health care provider before returning. If your child is diagnosed with “pink eye” or conjunctivitis, they must be on drops for at least 24 hours before returning.

Fever: If your child has a fever of 100.4 or greater, he/she should be kept home and must be fever free without the use of Tylenol or Ibuprofen for 24 hours before returning.

Nasal discharge, chronic cough or sore throat:  A child exhibiting any of these symptoms should be evaluated by your healthcare provider. These conditions could be contagious and require treatment. If an antibiotic is ordered by your healthcare provider, it must be taken for a full 24 hours before your child may return.

Diarrhea/ vomiting: Any child exhibiting 2 or more watery stools in 24 hours or vomiting should not be sent to school. The child should be free of diarrhea/ vomiting for at least 24 hours before returning.

Rash: Any child exhibiting a rash or a rash combined with fever should not be sent to school and evaluated by your healthcare provider. Any child exhibiting a suspicious rash at school will be sent home and need to have verification from your healthcare provider that the rash is not contagious.

Lice /Nits: Any child with lice or nits should remain home from school until their hair is free of lice /nits. After treatment and lice/nit removal, the child will need to be checked by Nursing in order to return to school. The child will not be transported by busing and will have to be brought in by parents.

Any child coming to school with the above symptoms puts all children and school staff members at risk for illness. We wish to keep all members of our school community safe and well. As always if you have any questions, feel free to contact us.

Lynnette Dechellis R.N.
Regina Poullas R.N.
Fairhaven School
420 Lincoln Way
Niles, Ohio 44446

Nursing Phone  330 652 -5811, ext 7