School Nurse Information

Medical Forms

• Authorization for Non-Prescription Medication at School

  For those students requiring a non-prescription medication to be given while at school (not already covered in the MRCA Student Medical Information/Waiver), this form must be completed, and an adult must turn it in to the nurse with the medication.

• Authorization for Prescription Medication at School

  For those students requiring prescription medications to be given while at school, this form must be completed by the student’s physician, and an adult must turn it into the nurse with the medication.

• Allergy Action Plan

  For those students who have severe allergies requiring medication, including Epi-Pens, this form must be completed and returned to the nurse by July 31 along with the Life-Threatening Allergy Parent Agreement Plan (below).

• Life-Threatening Allergy Parent Agreement Form

  For those students who have severe allergies requiring medication, including Epi-Pens, this form must be completed and returned to the nurse by July 31 along with the Allergy Action Plan (above).

• Authorization for Self-Administration/Carry of Medication at School

  For those students requiring a prescription medication to be self-administered/carried while at school, this form must be completed and returned to the nurse by the start of school.

• Authorization of Self Carry of Emergency Medication at School

  For students who need to carry an emergency prescription medication at school, a physician must complete this form. Please return it to the nurse by the start of school.

• Diabetes Parent Agreement - Independent Care
• Diabetes Parent Agreement - Dependent Care

  For students who have diabetes, one of the above forms (Independent Care or Dependent Care) must be completed and returned to the nurse prior to school as well as their child’s Diabetes Medical Management Plan (DMMP) signed by their physician.

• Seizure Emergency Action Plan

  A physician should complete this form if your child requires medication at school for seizures.

• HEADS UP SCHOOLS - A Fact Sheet for Parents

  For those students who have had a bump, blow, or jolt to the head, parents please read this fact sheet and seek medical attention right away for one or more of the symptoms of concussion listed.