Student Medical Forms

Family & Student

Student health forms assist in planning students' health. The nursing staff, educational team, and family need input and instructions from the health care provider to ensure that students receive the necessary support while in the school's care. Student health forms may be required if your student requires a 504 plan or IEP to succeed in school.

Medical Release Form
Provides permission for release of medical information by designated recipients. Must be signed by parent/guardian.
Medical Release Form - Spanish
Proporciona permiso para la divulgación de información médica por parte de destinatarios designados. Debe estar firmado por el padre/tutor.
Seizure Action Plan
Provides orders for care. Requires physician and parent signature.
Seizure Action Plan - Spanish
Proporciona órdenes de atención. Requiere la firma del médico y de los padres.
SCCPSS Parent Consent Form
Allows schools to be reimbursed from Medicaid for medical services provided to students. Requires parent/guardian signature.
Medication Self Carry Authorization
Provides permission for student to self-carry albuterol/epinephrine/glucagon. Must be signed by physician and parent/guardian.
Medication Authorization Form
Provides permission for student to receive medication at school. Must be signed by parent/guardian.
Medication Authorization Form - Spanish
Proporciona permiso para que el estudiante reciba medicamentos en la escuela. Debe estar firmado por el padre/tutor.
Medication Authorization Form for Single Student with Multiple Medications
Provides permission for a student to receive multiple medications while at school. Must be signed by parent/guardian.
Medication Authorization Form for Single Student with Multiple Medications - Spanish
Proporciona permiso para que un estudiante reciba múltiples medicamentos mientras está en la escuela. Debe estar firmado por el padre/tutor.
Food Allergy Action Plan
Provides care orders for a student with allergies. Must be signed by physician and parent/guardian.
Food Allergy Action Plan - Spanish
Proporciona órdenes de atención para un estudiante con alergias. Debe estar firmado por el médico y el padre/tutor.
Dietary Prescription Form
Provides orders for care. Must be signed by physician and parent/guardian
Dietary Prescription Form - Spanish
Proporciona órdenes de atención. Debe estar firmado por el médico y el padre/tutor
Diabetes Medical Management Plan
Provides orders for care. Must be signed by physician and parent/guardian.
Authorization to Give Medication on a Field Trip - Spanish
Proporciona permiso para que se administren medicamentos en una excursión. Debe estar firmado por un padre/tutor.
Authorization for Self-Administration of Asthma Medication
Provides permission for medication to be given on a field trip. Must be signed by a parent/guardian.
Diabetic Medical Management Plan - Spanish
Proporciona órdenes de atención. Debe estar firmado por el médico y el padre/tutor.
Authorization to Give Medication on a Field Trip-Spanish
Proporciona permiso para que se administren medicamentos en una excursión. Debe estar firmado por un padre/tutor.
Asthma Action Plan
Provides orders for care. Requires physician and parent signature.
Asthma Action Plan - Spanish
Proporciona órdenes de atención. Requiere la firma del médico y de los padres.

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