Nurse Alert Form - Lake Washington School District printable pdf download

Lake Washington School District

Nurse Alert Form

Information on this form should be filled out/updated for each new school year. Please complete this form and return as soon as possible.

In order to provide a safe and healthy environment for your child, this information will be reviewed by the school nurse and shared with

staff. Minor health conditions that will not affect your child at school do not need to be listed on this form.

Student Name ______________________________________________________________ Birth date ___________________

Last

First

Middle

School ______________________________________ Grade ___________ Teacher __________________________________

Serious Health Conditions

(check appropriate box below)

If your child has a serious health condition, it is vital that you discuss this with your school nurse immediately.

Washington state law (RCW 28A.210.320) requires that medication or treatment orders, medications and a health care

plan be in place prior to the start of school. Your school nurse will work with you to develop a health plan for your child.

Contact the school nurse through the school office.

My child does not have any health conditions that will affect him/her at school.

(If this box is checked, no further information is necessary. Please sign/date at bottom and return to school office.)

My child has the following serious health condition(s) – Check box(es) below:

Asthma - Will your child require an inhaler at school? ____________ (Yes or No)

Cardiac diagnosis: _________________________________________________

Restrictions: __________________________________________________

Diabetes (Date of diagnosis: __________________ )

Insulin pump

Independent

Insulin via pen

Dependent

Insulin via syringe

Life threatening allergy (Requires an EpiPen or Auvi-Q at school)

Allergens: _____________________________________________

Seizure Disorder (Type: ______________________________________________)

Medication(s): ______________________________________________________

Other serious health condition(s): _____________________________________________________________

Medications (prescription, supplements, and over-the-counter)

All medications given at school require an Authorization for Administration of Medication form available at

or at the school

office. All prescription medications must be in the original container with a pharmacy label that matches the health care provider orders.

Over-the-counter medications and supplements must be in the original container marked with the student’s name.

Medication(s) to be given at school: __________________________________ Medication(s) taken at home: _____________________________

Emergency Preparedness for Medical/Dietary Conditions

We request that parents/guardians of students with serious medical/dietary conditions provide medication and/or appropriate food to be kept

at school in case there is an emergency that would detain them at school. A three-day supply is requested.

Emergency Contact Information

Parent/guardian name ___________________________________________________ Primary phone __________________________________

Email address __________________________________________________________ Secondary phone ________________________________

Health care provider _____________________________________________________ Phone number __________________________________

Date __________________________________________

Parent signature ________________________________________________________

SP 41 | Updated 1/15

Nurse Alert Form - Lake Washington School District

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