Medication Forms

Most current forms can be found on the Nursing & Student Health Services website at 

Additional information that may be helpful:
Please Read Completely and Carefully!

1. All medications given at school or on a school sponsored field trip must have a medication form completed and on file in the school health office.

2. All medication forms must be dated after July 1st of the current year to be used for the upcoming school year! 

2. Please give all completed forms to the school nurse only!

3. OLD forms from previous years and incorrect or incomplete forms will NOT be accepted!

4. If you need help with any medication forms, please see DSA’s school nurse as she can direct you to the correct form to use for which medication. 

5. The doctor must approve, on the correct medication form, for your child to self-carry Epinephrine or Asthma Rescue Inhalers.  A self-carry contract will also need to be completed and your child will need to talk to the nurse before he/she/they are approved to self-carry these medications at school.

6. You, the parent or guardian, will need to provide any of the needed medication along with the correct medication form to the nurse.

7. Tylenol and Ibuprofen are NOT available by parent permission only or via a phone call!!  A “Student Medication/Treatment Release Agreement” form must be completed by you and a doctor and returned to the school nurse along with the ordered medication in an original or prescription bottle that matches the order.

8.  For students with Seizure Disorders
 Only 1 form is now needed for both the seizure action plan and emergency medication:
      **Go to the link given at the beginning to find the Seizure Action Plan and Medication Orders form

9.  For Students with Diabetes
     – Please provide the school nurse at the beginning of the school year (preferably 
        before school starts) with your child’s Health Care Provider Orders, signed by
        both the doctor and parent
You may also provide any back up supplies you would like to be stored in the clinic for the school year.
     – If your student is able to independently manage their diabetes,
       an “Independent Diabetes Management – Student Agreement” form
       must be completed by the student and parent and then the school nurse.
     Form:  Agreement-for-Student-Self-Management Diabetes – 2020

Diabetes Care Plans for at school and other forms will be created by the school nurse after receiving both the Health Care Provider Orders and, if applicable, the “Independent Management of Diabetes – Student Agreement” forms.  Care Plans, etc. will be sent home after created, most likely with your student, for you to review, make corrections if necessary, sign and return to the school nurse.

You may also contact DSA’s school nurse for medication forms.

Updates will be posted as available.