This is a two page form. Both sides must be printed and signed by parent/guardian.

This consent is necessary for parent/guardian to sign and provide to the Principal/ School Clinic for the purpose of obtaining school related care plans and medical guidance for the care of their child's medical needs while they are in school or attending school sponsored events or activities (i.e. field trips, after-school care, sports, etc.) 

This form is mandatory for students to be able to carry their Asthma Inhalers, Diastat, Intranasal Versed, Epi-Pen, or Diabetes supplies. 

A physician must complete and sign this form.