2021-2022 MEDICAL ALERT FORM

MEDICAL ALERT FORM

2021-2022
Dear Parent/Guardian,

If your child has an allergy or special medical condition that could impact their learning environment, please check the appropriate box below and fill out any necessary documents/paperwork.

If you do not feel that your child's condition or allergy warrants a Medical Management Inventory Assessment to be completed, please check the appropriate box below.
Student's Name*

First NameLast Name
Yes, I would like my child to have a medical management plan on file, to be shared with all appropriate staff members, for the following conditions (check all that apply). I WILL PROVIDE THE SCHOOL OFFICE A COPY OF THE PLAN.

Allergy Emergency Action PlanAsthma Action PlanDiabetes Action PlanSeizure Action PlanStudent Self-Administration/Self-Possession of Medication Action Plan (for students who require an Epi-Pen or Inhaler)
I do not feel my child needs to have a Medical Emergency Action Plan on file above and beyond normal emergency procedures, but need the school to be aware of the following:

Food AllergiesOther AllergiesMedical ConditionsCurrent MedicationsNo allergies or medical concerns at this time
Please describe any allergies or medical conditions referenced above:
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Should be Empty: