Health Care Plan Needs

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This form is to be filled out by parents of students with allergies, asthma, and other health needs and impairments.

Email *

Student's Name *

Health Need

Asthma

Allergy

Diabetes

Seizure Disorder

Other:

Does your child need to sit at a nut-free table during lunch?

Yes

N/A

Clear selection

Does your student take medication at home?

Yes

Clear selection

Do you want your student to have medication at school?

Yes- in the nurses office

Yes- Student will self-cary medication

Clear selection

If you answered "no" above, do you want your child to have a health care plan distributed to faculty and staff who come into contact with your child throughout the day? This is to alert staff to their allergies or other needs (Children who have medication at school will automatically have this distributed). *

Yes

N/A

Other:

Anything else you'd like me to know?

Please sign type your name as a virtual signature

Today's Date

YYYY

Best way to contact you?

Submit

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This form was created inside of East Prairie School District #73.

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