School Health Program

Listed below are the Medication Administration & Consent forms in the event your child requires medication to be kept at school. The forms require your signature and your child's medical provider's signature for Prescription medication and only your signature for OTC medications, along with dosage and administration instructions.

All medication/Action Plan forms must be dated after June 3, 2024.  All medication must be brought to the school office by an adult. Please do not send medication to school in a student's backpack.

Medication Administration Form
Anaphylaxis Allergy Plan
Asthma Action Plan (Sample)
Seizure Action Plan (Sample)
G Tube Authorization Form
Diabetes Supplies for School Checklist

Any Medications Taken during School Hours must have:

• Prescription Medications require a provider’s signature.
• Medication in the original bottle/prescription bottle with label attached. 
• Parent/guardian signature must be on the medication order form.

In order to Self-Carry Medications:

• The Provider must sign the self-carry section of the medication form. The self-carry medication must be approved by the District nurse.
• Self-carry medications per district policy are emergency medications such as inhalers, epinephrine pens, and diabetes medications.

Below you will find a list of school needs for some of the most common health conditions:  

Severe Allergies:

• Epinephrine in labeled box from pharmacy and/or Benadryl and Medication Consent Forms
• Allergy Action Plan from Medical Provider or attached sample plan

Asthma:

• Inhaler in the labeled box from the pharmacy and Medication Consent Form
• Asthma Action Plan from Medical Provider or attached action sample plan

Seizures, Diabetes:

• Diabetes medical management plan from the Medical Provider & supplies-see attached list
• Seizure Action Plan from Medical Provider or attached sample plan

G-Tube Usage:

• G-Tube orders for medications and feedings via the G-Tube signed by the Medical Provider.