Quick Link: Medication Forms

Asthma Treatment Plan

Asthma Treatment Plan to be completed by healthcare provider.

Asthma permission form to be signed by parent/guardian.

Submit both completed forms to nurse. Student is to self-carry rescue inhaler during the school day, for all after school sports or activities and for school trips, so it is available to the student when needed.

Daily or "as needed" medications

This form is to be completed by the healthcare provider and signed by the parent/guardian. ALL medications need to be administered by the school nurse. Students may not self-carry/self-administer any medications, not even Tylenol, Tums, ibuprofen, etc. Completed forms are to be submitted to the school nurse. Parents/guardians need to bring the medication to school (medications may not be brought to school by the student).

The school nurse does have a stock supply of acetaminophen (Tylenol), ibuprofen and Tums. If your student occasionally requests one of these medications, it may be administered by the school nurse at their discretion. Parent written permission by completing this form is required in order for your student to receive an occasional dose of acetaminophen, ibuprofen or Tums.

Epinephrine Autoinjector

Life-threatening allergy to peanuts, treenuts, any other foods, bees, or latex? Self-carry an Epi-pen, Auvi-Q or any other form of epinephrine? Have your student's healthcare provider complete these forms which also need to be signed by the parent/guardian. Submit completed forms to the nurse. Student is to self-carry epinephrine autoinjector during the school day, for all after school sports or activities and for school trips, so it is available to the student when needed.

Diabetes

The Diabetes Medical Management Plan needs to be completed by the student's healthcare provider and parent/guardian. Submit completed form to the school nurse. Students with diabetes may self-carry all their supplies on their person.

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