Emergency Action Health Care Plan Template (Page 2 of 2) in pdf

EMERGENCY ACTION HEALTH CARE PLAN ( Part 2 )

Dear Parent or Guardian:

The Lynchburg City Schools attempts to discourage administration of medication during school hours, and request

whenever possible medication doses be scheduled other than school hours. Recognizing that this is not always possible,

we will cooperate in giving medication that must be given during school time. Our regulations include:

1. Written orders using this form from a physician, detailing the name of the medication, dosage, route, and time

interval of medication to be taken and plan of care.

2. Using this form, the signature of the parent or guardian requesting that the school district comply

with the physician’s order and plan of care

3. Medication must be brought to school by the parent or guardian in a container appropriately

labeled by the pharmacy.

MEDICATION(S)

Medication

Dose

Diagnosis

Time Med to

Route

Side Effects

be Given

I have prescribed the medication(s) listed above and reviewed the Emergency Action Health Care Plan for this student. The

plan is in accordance with the student’s medical management.

□

Current School Year (please check and fill in current school year) 20______ to 20______

________________________________________________

__________________

Physicians Signature

Date

PARENTAL CONSENT

I give my permission for school personnel to follow the Emergency Action Health Care Plan and administer the

prescribed medications in accordance with the above instructions. I understand that I am responsible for

providing the school with the prescribed medication needed by my child. I acknowledge that I have read,

understand, and do now support the Emergency Action Health Care Plan as outlined on part 1 and part 2 of this

form. I agree to allow information on this Emergency Action Health Care Plan to be shared with the adults

responsible for my child’s care. I hereby release the Lynchburg City School Board, its employee and agents from

any claims or liability connected with its reliance on this permission and agree to indemnify, defend, and hold

them harmless from any claim or liability connected with such reliance. I am aware that should I move to another

attendance zone with Lynchburg City, I will need to work with the new school to continue with the above health

care plan for my child.

___________________________________________

_____________________________

Signature of Parent/Guardian

Date

___________________________________________

_____________________________

Signature of Nurse/Health Assistant

Date

A new Emergency Action Health Care Plan is required on an annual basis and a revision with any significant change in the student’s health status

Lynchburg City Schools Emergency Action Health Care Plan: Emergency Action Health Care Plan

Revised

06/26/13

Emergency Action Health Care Plan Template Page 2

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