Health Forms

2012-13 Health Forms and Documents

Last updated 12-0427 at 1:50 p.m.

Emergency Medical Form 2012-13 (Required)

Immunization Record Form 2012-13 (Required) 

Authorization for Self-Carry Administration of Medication Form 12-13

Authorization for School Personnel Administration of Medication Form 12-13

Request for Administration of Acetaminophen (Tylenol)/Ibuprofen (Advil) Form 12-13

Request for Administration of Diphenhydramine HC1 (Benadryl) Form 12-13

Asthma Management Form

Diabetes Medical Management Form

Food Allergies (or Bee Stings) Action Plan Form

Seizure Action Plan Form

 

Procedures

Medication Administration during Overnight School Trips, Sports and Extracurricular Activities

 

Health Conditions

Parents: If you indicated on the Emergency Medical Form that your child has a health condition, please complete all applicable health and medication forms, and return them to the school nurse. This information and medication authorization is mandatory for students who need medication at CJ.

Asthma

  • Complete and submit asthma form

  • Obtain medical authorization for the applicable medication form(s) to both self-carry and self-administer an inhaler, or to have an inhaler available in the clinic for use, or both. Medication must be labeled and dispensed in the original container.

Authorization for Self-Carry Administration of Medication Form

Authorization for School Personnel Administration of Medication Form

 

Diabetes

Authorization for Self-Carry Administration of Medication Form

Authorization for School Personnel Administration of Medication Form

 

Food Allergies or Bee Sting Allergies

  • Complete and submit the Food Allergy Action Plan Form

  • If your student has an allergy to bee stings, complete and submit the Food Allergy Action Plan Form, but cross out food allergy, and write in “BEE STING.”

  • Obtain medical authorization for the applicable medication form(s) to both self-carry and self-administer an EpiPen, or to have an EpiPen available in the clinic for use, or both. Medication must be labeled and dispensed in the original container.

Authorization for Self-Carry Administration of Medication Form

Authorization for School Personnel Administration of Medication Form

 

Seizure disorder

Authorization for Self-Carry Administration of Medication Form

Authorization for School Personnel Administration of Medication Form