Sample Forms

2018 SCH Authorization for Care and Use of Feeding Tube

2018 SCH Authorization For Clean Intermittent Catheterization Or Assisted Self-Catheterization at Sc

504 Parents' Rights

504 Prior Notice - Consent

Annual Health Record Update

Asthma History English

Asthma Medication Authorization

Authorization Release Health Information

Diabetes History

Diabetes IHP/504

Diabetes Parent Letter

Diabetes Planning Checklist

Discontinuation of Medication at School

General Medication Authorization

Hearing Referral form- English and Spanish

This is a suggested draft of a hearing referral form in English and Spanish.  Please make sure you make a copy for your files if you download it. Thank you.

Request for Special Dietary Accommodations

Federal law and USDA regulation require nutrition programs to make reasonable modifications to accommodate those with disabilities. Under the law, a disability is an impairment which substantially limits a major life activity or bodily function, which can include allergies and digestive conditions, but does not include personal diet preferences.

Rescinding Delegation Form

Sample Medication Delegation Documentation Form

Severe Allergy Medication Authorization

Student Skills Checklist for Self-Carry/Self-Administer

Vision Referral form - English and Spanish

This is a suggested draft form for Vision referrals.  If you choose to download this, please be sure to save a copy to your own drive. 

Thank you.