TLC! Coordinated Health Forms

In order to keep students safe while at school, we need information about all health conditions. To reduce paper waste, we are making these forms available online. If you do not have access to the school web page and a printer, you may pick up these forms in the main office.

If one or more of the following forms applies to your student, please select and open up the form(s) online, or you can request them in the main office. The forms should be filled out completely, signed by parent / guardian, and returned to the school main office. Please note that some forms also need to be signed by the student's physician (MD or DO). The signature of a Nurse Practitioner (NP or APRN) or licensed Physician Assistant (PA) will also be acceptable.

Request for Medication Administration in School – to be filled out by physician and signed by parent. This form should be completed for every student on campus that takes medication during the school day.

Student Agreement For Self-Carried Medication – This form is for students who carry and administer their own medication. It should be completed in addition to Request for Medication Administration in School.  The form should be signed by the physician and the student.   Example of when this form is needed: students who carry EpiPens, asthma inhalers, insulin. 

HF1 - Student Asthma Action Card – this form should be completed by physician and parent for any student with asthma, or any other reactive airway disorder that may require intervention during school hours.  This form includes emergency instructions for staff.

HF2 - Diabetes Care Plan – this is a set of forms to be completed by physician and parent for students with Diabetes Mellitus. These forms are found within the Individual Diabetes Care Plan Guidelines on pages 8 through 16. All pages need to be completed.    

HF3 - Food Allergy Action Plan (FAAP) – this form will be used for students with severe, life threatening food allergies.  It is not necessary to complete this form for the student with food sensitivities that are not life threatening. The FAAP should be filled out and signed by parent and physician.  If the student either carries, or has on campus, any of the following – EpiPen, Twinject, Adrenaclick, or any other form of Epinephrine, they should have this form completed. This form includes emergency instructions for staff.

HF3 - Allergy Action Plan (Bee Sting) – this form is for students with serious insect sting allergies. 

HF5 - Medical Statement for Students With Special Nutritional Needs for School Meals – this form should be completed by parent and physician for students with medical conditions that necessitate texture modifications in their diet.

Additional forms may be posted as needed. Please look on the school website at Naturallygrownkids.org, and click on the Health Forms tab on the left. Please return these forms to the school as soon as possible. We appreciate your cooperation in helping us to keep your student safe and healthy.