Health Office and Forms

Prescribed Medication Authorization Form  — This form is to be completed for any prescribed medication that is to be given during school hours.  Parents/guardians read and complete the top portion. Your health-care provider completes the bottom portion. Click the above link above to access a printable copy of this form. 

Life Threatening Food Allergy Action Plan — Please complete both sides of the Life-Threatening Allergy Action Plan.  This plan needs to be completed for each school year and does require a physician signature.  Please check to see that your child's medication has not expired before turning it in to the health office. Expired medications cannot be sent on field trips or administered in the school setting. 

Prescribed Medication Authorization Form  — This form must also be completed for any epinephrine auto injector that could be given during school hours.  Parents/guardians read and complete the top portion. Your health-care provider completes the bottom portion. Click the above link above to access a printable copy of this form. 

Life Threatening Allergy History Form — Complete this form once upon entrance to the school district or anytime there are significant changes.  

Authorization for Student Possession of and Use of an Epinephrine Autoinjector — Please complete this form if your student will carry and self-administer an epinephrine autoinjector. Recommended for middle school and high school students only.

Asthma History Form 

Asthma Action Plan and Prescription Medication Authorization

Parents/guardians, please fill out the Asthma History Form and complete the Asthma Action Plan and prescription authorization forms in conjunction with your child's primary care provider. These forms tell us about your student's asthma history, triggers, recent hospitalizations, and medications, and a new set will need completed for each school year.  

Authorization for Student Possession and Use of Asthma Inhaler — Parents/guardians, please complete this form if your student will carry and self-administer an asthma inhaler. Recommended for middle school and high school students only.

Seizure Action Plan Form — Parents/guardians, please complete this form if your child has a seizure action plan.  A physician signature is required as well as a parent/guardian signature on the second page.

Prescribed Medication Authorization Form — This form is to be completed for any prescribed medication that is to be given during school hours.  Parents/guardians read and complete the top portion. Your health-care provider completes the bottom portion. Click the above link above to access a printable copy of this form.  

Diabetes Care Plan — This is a sample of a diabetes care plan.  Your healthcare provider may have their own diabetes care plan completed for your child. Click the underlined link above to download a copy if desired.

If your student has been prescribed emergency glucagon, please know that our school nurses train the teachers each year how to administer this life-saving medication.  Your child's glucagon will be kept in the health clinic and will follow them on all field trips.

Prescribed Medication Authorization Form — If your student has been prescribed emergency glucagon, please have your physician complete the prescribed medication authorization form for glucagon.  This form does require both physician and parent/guardian signatures.

Authorization for Nonprescription Medication or Treatment — Upper Arlington's schools offer the ability to provide some nonprescription medication to students during the school day. Families are asked to complete a form during the registration and annual back-to-school forms process regarding the authorization for nonprescription medication or treatment in order for their student to be permitted to use nonprescription medications in school.

If families need to make any updates, you may complete the form above and submit it to your school nurse.