Medication Forms for 2019-20
1. Medications at school & / or field trips
2. Students with diabetes please see #5 below
3. Students with seizures please see #6 below
Please Read Completely and Carefully!
All 2019-2020 medication forms must be dated after July 1, 2019 to be used for the 2019-20 school year!
Please give all forms to the school nurse only or have them put in her mailbox!
OLD forms from previous years and incorrect or incomplete forms will NOT be accepted!
If you need help with any medication forms for the 2019-20 school year, please see DSA’s school nurse as she can direct you to the correct form to use for which medication.
The forms are also in the links below in case you need additional copies.
Please click on the attached forms below under each medication type.
1. For ALL medications given at school or on a school sponsored field trip except Epinephrine devises or Rescue Inhalers (Albuterol):
– A“General Med Treatment Release Agreement” form must be completed by the parent and doctor
– These forms are NOT for Epi-pens or Rescue Inhalers (Albuterol)!
NOTE: Tylenol and Ibuprofen are NO LONGER available by parent permission only or via a phone call!! A “General Med Treatment Release Agreement” form must be completed by a doctor and returned to the school nurse along with the ordered medication in an original or prescription bottle.
2. For Epinephrine devises like Epi-pens, Adrenaclick, Auvi-Q:
– An “Anaphylaxis Emergency Care Plan and Med Orders” form must be completed by a parent and a doctor.
– If the doctor also wants to order Benadryl, Zyrtec or another Antihistamine as part of the Anaphylaxis Plan then a “General Med Treatment Release Agreement” form must also be completed for the Benadryl or Antihistamine.
Note: There are additional forms & requirements below in #4 for a student to self- carry their Epinephrine devise.
Anaphylaxis Emergency Care Plan and Med Orders 19-20
General Med Treatment Release Agreement – English 19-20
General Med Treatment Release Agreement Spanish 19-20
3. For Rescue Inhalers (Albuterol) at school use the following plan and order:
CO Asthma Care Plan 2019-2020
Note: There are additional forms & requirements below in #4 for a student to self-carry their Rescue Inhaler (Albuterol).
4. Students may self-carry Epinephrine & Antihistamine or Rescue Inhalers (Albuterol) in school if:
– The doctor approves your child to self-carry on the
“Anaphylaxis Emergency Care Plan and Med Orders” or
“Asthma Plan and Med Orders” form.
– A “Self-Carry Epi-pen Contract” or “Self-Carry Rescue Inhaler Contract” is completed by the parent, student, and school nurse.
Contract to self-carry Epinephrine (& an antihistamine if part of plan / order):
Self-Carry Epi-pen Contract – Eng 19-20
Self-Carry Epi-pen Contract – Span 19-20
Contract to self-carry a Rescue Inhaler (Albuterol):
Self-Carry Rescue Inhaler Student Contract – Engish -19-20
Self-Carry Rescue Inhaler Student Contract – Spanish 19-20
5. 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.
Agreement-for-Students-Ind-Mgmt- Health Office
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.
6. For students with Seizure Disorders
Only 1 form is now needed for both the seizure action plan and emergency medication:
You may also contact DSA’s school nurse for medication forms.
Updates will be posted as available.