Floyd R. Shafer Elementary School

Medical Forms

The following forms can be printed and brought to your child's dentist/doctor if needed. Private physicals are due in Kindergarten, 1st Grade, 6th grade and 11th grade. Dental forms are due in Kindergarten or 1st grade, 3rd grade, and 7th grade. Special diets or restrictions must be received in writing and signed by your physician and diagnosis plan of care.

The following forms can be printed and brought to your child's dentist/doctor if needed. 

• Allergy Action Plan
• Asthma Action Plan
• Authorization to Release/Furnish Information Form
• Diabetic Plan of Care
• Dietary Restrictions
  
  • Dietary Restrictions Information
  • Dietary Restrictions Form
• Hypo & Hyperglycemia Symptom Sheet
• Medical Authorization Form
• Private Dental Exam Form
• Private Physician Physical Form
• Seizure Plan of Care
• Student Health Information Update Form

Medication Guidelines

 Medications will be given in school only in exceptional circumstances when the child's health may be jeopardized without it. A medication authorization form from the prescribing doctor or dentist shall be required. This statement shall include the name of the medication, the dose, the time to be given and possible reaction if any. Parent signature is also required. 

This procedure must be followed for prescription as well as over the counter medications.

The medication must be brought to school in a bottle marked with:

•   Name of students 

•   Name of physician 

•   Name of medication 

•   Time to be given 

•   The dosage

If this procedure is not followed, the medication will not be given.