Forms

FORMS (Please complete after July 1, 2024 for the upcoming school year)

    • All prescription medications, including Asthma and Allergy medications and dietary supplements, must have a written order from the physician stating the name of medication, the dosage, and the time to be given.
    • Please fully complete and sign the medication forms and bring them to the Health Office.
    • Medicine must be in the original bottle as prescribed by a physician or in the original over-the-counter bottle.  
    • We cannot accept expired medication.
    • Parents are responsible for bringing in medication, including cough drops, to the Health Office. 
    • All medication must be distributed by the nurse, unless addressed in a medical-assistance plan.

     

    Medication Doctors Order Form:  

    Medication Authorization Form

    Dr. signature required on the medication authorization form

     

    Mar Log for health office

    Medication Log

     

    All medical packets below will need a medication doctor order form (above) if you are planning on having medications for your student in the health office.

    Allergy Packet (need epi pen, benadryl, etc.)

    Allergy history

    Action Plan (Dr. signature required)

    Peanut/Nut Allergy Cafeteria table seating

    Special Diet Request for known Allergies only (Dr. signature required)

     

    Asthma 

    Action plan for school (Dr. signature required)

    Self-carry inhaler/epi pen authorization

     

    Diabetes (a plan from your provider is also accepted, but a plan must be on file for the school year and updated whenever there are changes)

    Absence of Nurse

    Technology Agreement

    Diabetes Questionnaire 

    Diabetic Treatment Plan (Dr. signature required)

    Self Management (Dr. signature required)

    Bus Rider form

    Supply Checklist for school/all classrooms (each classroom from 4th grade and above will need supplies in the event of an emergency, including special areas)

     

    Seizures

    Action Plan for School (Dr. signature required)

    Seizure information sheet

     

    Student Individual Emergency Medical Plan (Dr. signature required) all other medical conditions that may require a plan in place for school  

    Bus Rider Form for Allergies, Seizures, Asthma

     

    * The forms above must be completed on or after July 1, 2024 for the upcoming school year. If dated prior to July 1, 2024 the forms will need to be resubmitted. Thank you.*