Clinic and Nutrition Forms

Authorization for administration of Prescribed Medication(s)/Medical Procedures

A completed form must be on file for each student requiring medication administration and/or medical procedures.

Medication Form - Release and HIPPA Clause.pdf
Authorization for Administration of Prescribed Medication Policy.pdf

School Nutrition Department Medical Statement and Diet Prescription for Meals at School

This form is for students who are unable to consume food(s) because of medical or other special dietary needs. It will need to be completed by one of the following medical authorities: physician, physician assistant, nurse practitioner or registered/licensed dietitian. The first section (“Describe the student’s handicap and the major life activities affected by it”) does not have to be completed by the appropriate medical authority when a student is not diagnosed “handicapped”. Upon receiving the completed form, the requested dietary changes will be made by the school nutrition department.

Centennial Diet Rx Form.pdf

Student Asthma Action Card

This form explains steps to be taken for various symptoms during as asthma episode while in school as well as emergency contacts. It is always kept with the student’s medication and travels with the student’s teacher when going on field trips. This form will need to be completed by your child's health care provider along with the medication administration form.

StudentAsthmaActionCard.pdf

Food Allergy Emergency Plan

This form explains steps to be taken for a student displaying food allergy symptoms as well as emergency contacts. It outlines which medication is used for the presenting symptoms and emergency procedures to follow. It is always kept with the student’s medication and travels with the student’s teacher when going on field trips. It must be completed by your child's health provider along with the medication administration form.

Food allergy emergency plan.pdf