Parent Liaison / Medicine at School Forms

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The proper medical forms must be filled out and submitted to the school nurse prior to your child bringing medication to school. For additional information, please contract our school nurse, Ms. Lunsford.

Authorization for Medication Administration Form

Asthma Physician’s Orders/Health Care Plan

Diabetes: Part 1 Contact Information and Diabetes Medical History
To be completed by parent/guardian and returned to school nurse (prior to beginning of each school year or upon diagnosis. Includes: Parent authorization for trained school designees to administer insulin and/or glucagon (required by Virginia Law).

Diabetes: Part 2 and 3 for Physician's Use
To be completed by the physcian http://www.virginiadiabetes.org/resources.html

Diabetes: Part 4 Permission to Self-Carry and Self Administer Diabetes Care

To be completed by physician/provider, parent/guardian and student.

Seizure Physician’s Orders/Health Care Plan

Severe Allergy Physician’s Orders/Health Care Plan

Last Modified on December 22, 2010

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