Medical Forms

Health Care Plans

Students with one or more of the following medical conditions or any medical condition that may require intervention by staff during the school day require an up to date health care plan each year. If your student may need epinephrine, allergy, asthma, or seizure medications the medication permission is within the health care packets and you do not need to fill out the Prescription Medication Authorization form in addition. For diabetic supplies and all other prescription medications you will need a Prescription Authorization Form signed by your students health care provider for each medication.

Students may be allowed to assume responsibility for carrying and administering their own medications such as asthma medication, epinephrine, or diabetes medication provided that self-administration is approved in writing by the prescribing health care provider, the parent or guardian, and the school nurse approves. 

• Allergy & Anaphylaxis Care Plan

• Asthma Care Plan

• Diabetes Care Plan Part 1

• Diabetes Medication Management Orders

• Diabetes Emergency Action Plan

• Diabetes Continuous Glucose Monitor

• General Health Care Plan

• Seizure Care Plan

• Seizures Medications Form

Additional Medication Forms

• Over-The-Counter and Prescription Medication Information

• Over-the-Counter Medication Form

• Prescription Medication Authorization Form

Other Forms/Policies

• Authorization to Release Information

• Informed Consent

• General Illness Policy

• Wellness Policy

If you have any questions or concerns please contact:

Natasha Breakall RN, BSN

School Nurse

North Salt Lake Spectrum Academy

801-936-0318 x 7012 

natasha.breakall@spectrumcharter.org

Anna M Deltejo RN, BSN

School Nurse

Pleasant Grove Spectrum Academy

anna.deltejo@spectrumcharter.org

​

​

​

​

​