Medication Permission Form
The Medication Permission Form must be on file (filled out and signed by a parent/guardian) for ANY medication that may be given to a student in the clinic during school hours. In addition to the medication form, an action plan should be on file for any conditions that apply.
Medication Request and Authorization forms:
Medication not allowed by the district:
Allergy Action Plan
An Allergy Action Plan must be kept on file in the clinic for any student who has a reported food allergy. A parent and physician signature is required.
Asthma Action Plan
An Asthma Action Plan must be kept on file in the clinic for any student with asthma. **Students in grades 3-6 may keep their inhaler with them in their backpack at school and self-administer it as necessary. A "Self-Carrying Inhaler Student/Parent Agreement" form must be on file in the clinic if the student, parent, and physician agree that the student may carry and administer their own inhaler at school.
Student/Parent Agreement for Self-Carrying/Administering an Inhaler at School
Students in grades 3-6 whose parents and physicians approve the self-carrying and administartion of the inhaler by the student while in school must have this agreement on file in the clinic.
Seizure Action Plan
A Seizure Action Plan must be kept on file in the clinic. A physician and parent signature is required.
DIABETIC CARE PLAN
Any student that is Diabetic, needs to complete a UDCA form below if they will allow a staff member other than the nurse to assist in diabetic care. Diabetic care plan from physician is required.