Student Medical Forms

Student Medical Forms - Optional

Food Allergies, Medications, etc
Student Name *

First Name Last Name
Grade Level *
Parent/Guardian 1 Name *

First Name Last Name
Parent/Guardian 2 Name

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
All of these medical forms are optional. Please fill out only those that your family needs.
Food Allergy

MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS
Check One:

The student has a disability or a medical condition and requires a special meal or accommodation (Refer to the definitions below). Schools participating in the National School Lunch Program must comply with requests for special meals and any adaptive equipment. The student does not have a disability, but is requesting a special meal or accommodation due to food intolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schools participating in the National School Lunch Program are encouraged to accommodate reasonable requests.
Disability or medical condition requiring a special meal or accommodation:
If the student has a disability, provide a brief description of the student’s major life activity affected by the disability:
Diet prescription and/or accommodation: Please describe in detail to ensure proper implementation.
Indicate texture modification request (if applicable), ie: Ground, Soft, Pureed, Liquid
Please list specific foods to be omitted and suggested substitutions – use extra pages if needed.
Adaptive Equipment Required:
Parent/Guardian 1 Signature

Clear
DEFINITIONS*

“A Person with a Disability” is defined as any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such an impairment.

“Physical or mental impairment” means

(a) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive, digestive, genito-urinary; hemic and lymphatic; skin; and endocrine; or

(b) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.

“Major life activities” include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.

“Has a record of such an impairment” is defined as having a history of, or have been classified (or misclassified) as having a mental or physical impairment that substantially limits one or more major life activities.

(*Citations from Section 504 of the Rehabilitation Act of 1973 and Americans with Disabilities Act of 1990)

AUTHORIZATION TO CARRY AND SELF-ADMINISTERED METERED-DOSE INHALER FOR ASTHMA

A NEW AUTHORIZATION IS REQUIRED EACH YEAR
Parent/GuardianPermission:

I hereby request and give permission for my child to be allowed to carry and self‐administer their MDI (MeteredDoseInhaler) per Florida State Statute, while in school and away from school for activities, according to written directions from my child’s physician, as outlined below. I will notify the school immediately if the health status of my child changes, we change physicians, we change home, work,or emergency telephone numbers, or there is a change or cancellation of the medication order. I understand that it is my responsibility to ensure that my child has a functioning, labeled inhaler within the expiration date of their use.
Yes No
Name of Medication
Dosage
How long is this authorization effective?

Month Day Year
Date
Special Instructions
Parent/Guardian 1 Signature

Clear
Date Signed

Month Day Year
Date

Authorization For Over-The-Counter (OTC) Medication Administration
We encourage parents to make every attempt to have medications administered during non-school hours. However, in the event that it is not possible for medications to be administered at home this Authorization for OTC Medication Administration must be completed before the school may give the medication to the student. If your child requires medication during the school day the following rules must be observed:
- All medications must be personally brought into the school by the student’s parent/guardian accompanied by the appropriate required paperwork.
- Over-the-counter (OTC) medication must be received in the original container and labeled with the student’s name and accompanied by an Authorization for Medication Administration. OTC medications do not require the signature of a health care provider.
- Absolutely no OTC medications will be administered by school staff to students without appropriate documentation, and unless provided by the parents.
List the condition(s) or disease(s) for which this medication is meant to address
Name of medication
Dosage
How long is this authorization effective?

Month Day Year
Date
When should this medication be given?
ie: after lunch, at 2:15pm, etc
I request the designated school personnel to assist my child in the administration of the above described medication. I give permission for my child to take this medication while in school or while participating in school activities away from the school site. I understand that: (1) there is no liability on the part of the charter school, school district, its personnel, or agents, including the County Health Department personnel, for civil damages as a result of the administration of this medication to my child when the person administering the medication acts as an ordinarily reasonably prudent person would have acted under the same or similar circumstances; (2) this medication must be brought to the school only by a responsible adult; (3) this medication must be in its original labeled container; (4) this medication will be destroyed if it is not picked up within one week following the above stop date or one week after the close of the current school year, whichever occurs first.

Non-prescription medication requests must be renewed by the parent/guardian and release signed by the parent/guardian annually. Each medication, or any change in medication, requires a new form. The parent/guardian will be responsible for ensuring that medicines provided for the school have not expired.
Parent/Guardian 1 Signature

Clear
Date Signed

Month Day Year
Date

Authorization for Administration of Prescription Medication
We encourage parents to make every attempt to have medications administered during non-school hours. However, in the event that it is not possible for medications to be administered at home this Authorization for Administration of Prescription Medication must be completed before the school may give the medication to the student. If your child requires medication during the school day the following rules must be observed:
- All medications must be personally brought into the school by the student’s parent/guardian accompanied by the appropriate required paperwork.
- All prescription medications require written Authorization for Medication Administration, with original signature by the parent and health care provider before the school shall accept the medication.
- Prescription Medication/Treatment must be received in a pharmacy labeled container with the student’s name, healthcare provider’s name, name of pharmacy and phone number, name of medication, directions for dosage and date of prescription.
- School personnel shall not administer medication if there is a change in type, dosage or frequency unless a new written Authorization for Medication Administration with original signature by the parent and health care provider is presented to the school official.
List the condition(s) or disease(s) being treated
How long will your child need this medication

Month Day Year
Date
Physician’s Name

First Name Last Name
Physician’s Phone Number

Area Code Phone Number
Medication must be in a properly labeled container prepared by a pharmacist (a prescription), or the manufacturer (non-prescription eye drops). The container must contain the student’s name, medication name, dose of the medication, and when to take the medication. Ask your pharmacist for a duplicate prescription container at no extra charge for taking the medication to school.

List Medications taken at school

Medication

Time of Day

Dose

Refrigerated?

Medication 1

Medication 2

Medication 3

Has your child ever had a problem with any of these medications?
Is there anything else you would like us to know about your child & this medicine?
Consent: As legal parent or guardian, I hereby authorize my child to take the medication that I will provide, and that is listed in the above profile, and further authorize the school to store these medication according to school policies, and assist with administration of the medication as directed. I further agree to inform the school of any changes in the medication, including changes in when the medication is taken, change in the dose, new or different medication, a reaction to the medication, or discontinuation of medication. I further understand that this consent applies to all medication, whether prescribed by a physician, or purchased over the counter without a prescription. I understand that this consent applies for this school year only, and next year I am required to sign another consent form.
Signature

Clear
Date Signed

Month Day Year
Date
Should be Empty:

Student Medical Forms - Optional

Food Allergy

AUTHORIZATION TO CARRY AND SELF-ADMINISTERED METERED-DOSE INHALER FOR ASTHMA

Authorization For Over-The-Counter (OTC) Medication Administration

Authorization for Administration of Prescription Medication