Students requiring emergency care plan(s) and/or medication(s) that need to be given during school hours will need one or more of the following forms completed.
Prior to the beginning of each school year, emergency care plans and medication authorizations should be turned in to your child's school health office and reviewed with your Licensed School Nurse.
- RPS Health Information Form
- RPS Anaphylaxis Emergency Care Plan
- RPS Seizure Emergency Care Plan
- Consent to Share Asthma Action Plan and Information About My Child
- Medication Authorization Form (Staff Administration)
- Consent to Release Private Data
- Diabetes Medical Management Plan (DMMP)
- Food Intolerances/Allergies Forms
- Special Diet Statement Form
This form gives the school authorization to administer epinephrine (e.g. EpiPen, Auvi-Q) to a child during an anaphylactic reaction (life-threatening allergic reaction) during the school day.
This form should be completed for students that have a seizure disorder. If there is a seizure medication that will be kept at school, you will need a physician's signature.
Asthma Action Plans need to be completed for students with asthma. Asthma Action Plans can be requested from your HealthCare Provider. It is electronically signed by your child's physician and is valid for a year from the signature date.
Complete this form if your child needs a medication given during school hours. A Health Care Provider’s signature is required. More information about medication administration at school can be found under Rochester Public Schools medication policy 516 or by contacting the Licensed School Nurse at your child's school.
- Students can carry prescription medicine with them (for example, an asthma rescue inhaler) if they have written consent from parent/guardian and their licensed health care provider. In addition, the Licensed School Nurse will need to meet with the student to ensure that they can safely and successfully carry their own medicine. Contact your child's Licensed School Nurse for the appropriate form.
- Secondary students can carry over-the-counter non-prescription pain relievers (for example, ibuprofen or acetaminophen) if they have written consent from parent/guardian. In addition, the Licensed School Nurse will need to meet with the student and ensure that they can safely and successfully carry their own medicine. Contact your child's Licensed School Nurse for the appropriate form.
To exchange information with an outside agency regarding your child’s emergency care plan(s) or medical condition(s). This form is requested of all children with emergency care plan(s) or medical condition(s).
This form should be completed by the parent and reviewed with the Licensed School Nurse for a student with diabetes. An Authorization for Medication Administration Form or a written order signed by a physician for medications (e.g. insulin, glucagon) is also required. Parents are responsible to bring all diabetic supplies (e.g. test strips, meter, insulin, needles, syringe, glucagon, snacks, glucose tabs, ketone strips) to the health office prior to the beginning of the school year.
This form provides guidelines for your child’s classroom and special area classrooms. If your child will be eating school meals and/or taking a beverage and will be needing substitutions due to a food intolerance or allergy, please contact Student Nutrition Services at (507) 328-4250.
ONLY complete for Early Childhood and Elementary Students.
This form needs to be completed by your child's physician. It gives Rochester Public Schools Student Nutrition Services direction on appropriate meal substitutions for a child's special diet (e.g. food allergies that result in severe, life-threatening (anaphylactic) reactions).