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PLEASE NOTE:
Each form is listed twice. The first is in PDF format. The second is an RTF file which is required for compliance with the
Americans with Disabilities Act
.
Medication Forms
5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel
5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel
5330 F2 Request for Student to Carry and Administer Own Prescription Medication by Inhaler
5330 F2 Request for Student to Carry and Administer Own Prescription Medication by Inhaler (.rtf)
5330 F4 (HS/MS) Request for Student to Self-Administer Nonprescription Medication w/o Supervision
5330 F4 (HS/MS) Request for Student to Self-Administer Nonprescription Medication w/o Supervision (.
5330A F1 Consent for Diabetic Management
5330A F1 Consent for Diabetic Management (.rtf)
5330A E F1 Allergy and Anaphylaxis Emergency Orders and Action Plan
5330A E F1 Allergy and Anaphylaxis Emergency Orders and Action Plan (.rtf)
Asthma / Allergy Forms
5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel
5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel
5330 F2 Request for Student to Carry and Administer Own Prescription Medication by Inhaler
5330 F2 Request for Student to Carry and Administer Own Prescription Medication by Inhaler (.rtf)
5330A E F1 Allergy and Anaphylaxis Emergency Orders and Action Plan
5330A E F1 Allergy and Anaphylaxis Emergency Orders and Action Plan (.rtf)
5335 F1 / 5340 F4 Parent/Guardian Information on Child's Life-Threatening Allergy
5335 F1 / 5340 F4 Parent/Guardian Information on Child's Life-Threatening Allergy (.rtf)
5340 F6 Parent-Guardian Information on Child's Asthma
5340 F6 Parent-Guardian Information on Child's Asthma (.rtf)
Assisted Feeding Forms
5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel
5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel
5311 F2 Health Care Provider Authorization and Recommendations for Assisted Oral Feedings
5311 F2 Health Care Provider Authorization and Recommendations for Assisted Oral Feedings (.rtf)
5311 F3 Health Care Provider Authorization and Recommendations for Assisted Tube Feedings
5311 F3 Health Care Provider Authorization and Recommendations for Assisted Tube Feedings (.rtf)
5311 F4 Emergency Procedures for Gastrostomy (G) or Gastrojejunostomy (GJ) Tubes
5311 F4 Emergency Procedures for Gastrostomy (G) or Gastrojejunostomy (GJ) Tubes (.rtf)
5311 F10 Parent Agreement for Mic-Key Gastrostomy (G) Tube Re-insertion
5311 F10 Parent Agreement for Mic-Key Gastrostomy (G) Tube Re-insertion (.rtf)
Catheter Forms
5330 C F1 Request for Clean Intermittent Catheterization by School Personnel
5330 C F1 Request for Clean Intermittent Catheterization by School Personnel (.rtf)
Immunization Forms
5320 F2 Immunization Exemption
5320 F2 Immunization Exemption (.rtf)
Private Provider Forms
3120.091 F1 Private Provider Plan
3120.091 F1 Private Provider Plan (.rtf)
3120.091 F2 Liability Release for Parent/Guardian of Student Receiving Private Provider Services or
3120.091 F2 Liability Release for Parent/Guardian of Student Receiving Private Provider Services or
3120.091 F3 Liability Release for Private Providers
3120.091 F3 Liability Release for Private Providers (.rtf)
Seizure Care Forms
5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel
5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel
5340 F5 Parent-Guardian Information on Child's Seizure Disorder
5340 F5 Parent-Guardian Information on Child's Seizure Disorder (.rtf)
TB Forms
5320 F3 District Tuberculosis Testing Form
5320 F3 District Tuberculosis Testing Form (.rtf)
Other Medical / Health Services Forms
2340C F1 District-Sponsored Overnight Trips Medical Permission Form
2340C F1 District-Sponsored Overnight Trips Medical Permission Form (.rtf)
2340C F1a 6th Grade Outdoor Education District-Sponsored Overnight Trips Medical Permission Form
2340C F1a 6th Grade Outdoor Education District-Sponsored Overnight Trips Medical Permission Form (.r
2412 F2 Home Instruction Physician Referral
2412 F2 Home Instruction Physician Referral (.rtf)
5112 F2 Preschool Health Assessment Record
5112 F2 Preschool Health Assessment Record (.rtf)
5310 F1 Student Health History Form
5310 F1 Student Health History Form (.rtf)
5320 F4 Parent Varicella (Chicken Pox) Report Form
5320 F4 Parent Varicella (Chicken Pox) Report Form (.rtf)
5320 F5 Medical Provider Review and Determination of Parent Reported Varicella
5320 F5 Medical Provider Review and Determination of Parent Reported Varicella (.rtf)
8330 F4a Parent Consent for Record Release Form
8330 F4a Parent Consent for Record Release Form (.rtf)
8431 F2 Advisory of Pesticide Application in Classroom Buildings
8431 F2 Advisory of Pesticide Application in Classroom Buildings (.rtf)
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