FORMS

• 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

https://drive.google.com/file/d/1aZa53mIocOCe73QZjPAAcWyCXXI_uA8k/view?usp=sharing

Action Plan (Dr. signature required)

https://drive.google.com/file/d/1Rzo-PoQkmoMPzbFx3tTvsTqOdIQ_FrZB/view?usp=sharing

Peanut/Nut Allergy Cafeteria table seating

https://drive.google.com/file/d/1zWya2-3Whm9iz8f2TEpsW-WiXQI1u6B-/view?usp=sharing

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

https://drive.google.com/file/d/1mLW4ot_CJCf6LKntFdZYi8I8oH4p1RTb/view?usp=sharing

 

Asthma 

Action plan for school (Dr. signature required)

https://docs.google.com/document/d/1IgKhDsW3Cpg4FJyBFMEQvpIPmX7HB81Y/edit?usp=sharing&ouid=104508590558159945595&rtpof=true&sd=true

Self-carry inhaler/epi pen authorization

https://docs.google.com/document/d/1zR4xQpky3YengmnUeLDBHQ2OrnB5wGfS/edit?usp=sharing&ouid=104508590558159945595&rtpof=true&sd=true

 

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

https://docs.google.com/document/d/1eyMGB7LH9SA1g4P6OWvLk3ef1gLzM2Dc/edit?usp=sharing&ouid=104508590558159945595&rtpof=true&sd=true

Technology Agreement

https://docs.google.com/document/d/1V3uvOEfddwan9o5poBA5aK7Us9q4Uozm/edit?usp=sharing&ouid=104508590558159945595&rtpof=true&sd=true

Diabetes Questionnaire 

https://drive.google.com/file/d/1E0GYn0jMS1uAUP9xbmEx-huF8BE_s8X9/view?usp=sharing

Diabetic Treatment Plan (Dr. signature required)

https://drive.google.com/file/d/1ZJudhQDMsH2_aMmwY6V6w1YUuZKW5TLD/view?usp=sharing

Self Management (Dr. signature required)

https://drive.google.com/file/d/1k9ofunpSe8IHHnd0yJ18yymX1kJ3RIEt/view?usp=sharing

Bus Rider form

https://drive.google.com/file/d/1I3KBkBb6qlpFXoiqYWYnRPoeyJF4riFj/view?usp=sharing

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)

https://docs.google.com/document/d/10wemfgG74Mj9waKaDmJ8oqJGIMIbu1Uj/edit?usp=sharing&ouid=104508590558159945595&rtpof=true&sd=true

 

Seizures

Action Plan for School (Dr. signature required)

https://docs.google.com/document/d/18-dLz7Km8CcSSEbe_kKAf_0MZ1s3hqj_/edit?usp=sharing&ouid=104508590558159945595&rtpof=true&sd=true

Seizure information sheet

https://docs.google.com/document/d/1TxwmBNkjcnmpNQv2XNP3zvhDGIbIj5mW/edit?usp=sharing&ouid=104508590558159945595&rtpof=true&sd=true

 

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

https://drive.google.com/file/d/1kA-1OMxucoFjfh4d5yWVQyX9LzDFUC5x/view?usp=sharing

Bus Rider Form for Allergies, Seizures, Asthma

https://drive.google.com/file/d/1sGvVYefXgh9XRjNSUKz5oPCt6ep2JKT_/view?usp=sharing

 

* 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.*