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Seizure Action Plan
If your son/daughter has seizures, please have your physician fill out this form so that we can plan for his/her care at school.
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Dietary Accommodation Request (To Be Filled Out By Health Care Professionals)
To request a dietary accommodation, this form MUST be filled out and submitted to Sibley East Health Services.
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Self Carry Medication Form
Students in 7-12 grade may have their own pain medication at school if this form is filled out and returned.
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Permission to give over the counter medication at school
If your child has headaches, new braces, recent injuries, or other conditions which might require the use of over the counter medications like Tylenol or ibuprofen, and you would like the Health Office to administer the medication to your child, please complete this form and send bring or send it to the Health Office with the medication.
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Prescription Medication Permission Form
If your son/daughter needs to have prescription medication give at school, please fill out and return this form with the medication in its original container.
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Anaphylaxis Emergency Action Plan
“If your son or daughter has an allergy which requires the use of medications such as Benadryl or an Epi-Pen to protect him/her from a serious reaction to his/her allergen, please have your physician fill this form out and return it to the Health Office. If your son or daughter has an Epi-Pen, please talk to him/her about the importance of keeping the Epi-Pen with him/her.”
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Spanish - Anafilaxia - Plan de accion para emergencias
“If your son or daughter has an allergy which requires the use of medications such as Benadryl or an Epi-Pen to protect him/her from a serious reaction to his/her allergen, please have your physician fill this form out and return it to the Health Office. If your son or daughter has an Epi-Pen, please talk to him/her about the importance of keeping the Epi-Pen with him/her.”
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Asthma Action Plan
The Asthma Action Plan can be completed by your child's health care provider. This can also serve as a doctor's order for asthma-related medication, i.e., inhaler, nebulizer.
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Spanish Asthma Action Plan
The Asthma Action Plan can be completed by your child's health care provider. This can also serve as a doctor's order for asthma-related medication, i.e., inhaler, nebulizer.

El Plan de Accion del Asma puede ser completado por su proveedor de cuidado de salud. Esto tambien puede servir como una orden del doctor para medicamento relacionado con asthma, inhalador, nebulizador.

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Diabetes Action Plan
If your child is diabetic, please work with your child's physician to complete this form. It will become your child's care plan for the time he/she is at school. If your child's physician has another short form that he/she prefers, that is acceptable. The form should be no longer than one page on both sides of the page, though.
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