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Health Forms

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

This form should be completed for all new students to Rochester Public Schools and those entering kindergarten, 3rd, 6th and 9th grades.

Health Information Form

RPS Anaphylaxis Emergency Care Plan

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.

Anaphylaxis Emergency Care Plan

RPS Seizure Emergency Care Plan

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.

Seizure Emergency Care Plan

Consent to Share Asthma Action Plan and Information About My Child

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.​

Consent to Share Asthma Action Plan

Medication Authorization Form (Staff Administration)

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.

Medication Authorization Form for Staff Administration

Consent to Release Private Data

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).

Consent to Release Private Data

Diabetes Medical Management Plan (DMMP)

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.

Diabetes Medical Management Plan (DMMP)
Diabetes Insulin Therapy: Base Dosages and Correction Scale

Food Intolerances/Allergies Forms

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.

Food Intolerances/Allergies Forms

Special Diet Statement Form

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).

Special Diet Statement Form