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 ONLY IF AGREED TO BY PHYSICIAN. A "Self-Carrying Inhaler Student/Parent Agreement" (Asthma Action Plan) form must be on file in the clinic if the nurse, parent, and physician agree that the student may carry and administer their own inhaler at school. This needs to be updated yearly by the physician.
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. A diabetic care plan from a physician is required.
Camp/Trip Medical and Emergency Information
This is the form that needs to be filled out for all students going to Sky Ranch. If a student needs additional medication, a medicine permission form (above) must also be filled out for each student and for each med.