Please print, complete, and sign all forms pertaining to your child's condition and return to the campus nurse.  Any changes to prescription medication administration, such as dosage and/or time to administer, require a physician's written order.  Medication orders are valid for the current school year/summer school session only.

Please be sure to print a separate Medication Administration Authorization Form for EACH medication to be administered at school in addition to the other forms below if the medication order is not part of the Management/Treatment Plan.

• Adrenal Insufficiency

  • Adrenal Insufficiency Medical Management Plan

  • Adrenal Insufficiency Health History

• Allergies

  • Allergy & Anaphylaxis Health History

  • Child Nutrition Diet Modification Form

  • Don't forget the above Medication Administration Authorization Form for each Medication to be stored in the clinic!

• Asthma

  • Asthma Health History

  • Don't forget the above Medication Administration Authorization Form for each Medication to be stored in the clinic!

• Diabetes

  • Diabetes Medical Management Plan Letter

  • UDCA Acknowledgement and Permission Form

• Seizure Disorder

  • TEA Seizure Management and Treatment Plan

• Specialized Healthcare Physician Orders

  • Enteral Tube Feeding Physician Orders for School

  • Balloon Type G-Button Reinsertion Physician Orders for School

  • Catheterization Physician Orders for School

  • Nasal and Oral Suction Physician Orders for School

  • Mechanical Insufflation/Exsufflation (Cough Assist) Physician Orders for School

  • Other (Not listed above) Procedure Physician Orders for School

Medications for the emergency treatment of Asthma and Life Threatening Food Allergies can be considered for self-carry and administration if certain requirements are met. Please review this form carefully and discuss with your school nurse.

Medication CANNOT be carried by students without completion of all steps and discussion with the school nurse.

Permission to Self-Carry and Self-Administer Medication Form