MENU

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.

  


Click above logo to download Free Adobe reader software for viewing and completing the forms below.

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.

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.

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.

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 Health Care Provider.  It is electronically signed by your child's physician and is valid for a year from the signature date.​

Authorization for Administration of Medication
Complete this form if your child needs a medication given during school hours.  A Health Care Provider’s signature is required for all prescription medications and for over-the-counter medications exceeding package recommendations.  More information about medication administration at school can be found under Rochester Public Schools medication policy 516.​

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).

Diabetes Medical Management Plan (DMMP)
Diabetes Insulin Therapy: Base Dosages & Correction Scale
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.​

Food Intolerances/Allergies Forms

ONLY complete for Early Childhood and Elementary Students.
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 or visit their webpage at

http://rochester.k12.mn.us/departments/student_nutrition_services

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).

Website by SchoolMessenger Presence. © 2017 West Corporation. All rights reserved.

Rochester Public Schools does not discriminate on the basis of race, color, creed, religion, national origin, sex, age, marital status, status with regard to public assistance, sexual orientation, or disability.