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.

Please email Nurse Alicia to request any of the forms listed below:
aslagle@goodhue.k12.mn.us
Fax: 651-800-9228

Authorization For Administration Of Medication Form:
Complete the authorization for administration of medication 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.

*Please note that any and all medication must be brought to school by an adult in the original labeled prescription container or in unopened over-the-counter packaging. Students cannot carry their own medications to the health office. Please bring no more than a 30 day supply at a time.

School Health Information Form:
This form should be completed for all students in Goodhue Public Schools grade Kindergarten, and whenever there are changes in your child's health. It is also need for all students that are new to the district. This form should also be completed for students that are being evaluated for special education or 504 plans

Special Diet Statement (Prek - Grade 12) :
This form provides guidelines for managing a student’s food allergy/intolerance to appropriate staff members (e.g. nursing, dietary, classroom teacher(s), special areas). Required ONE time per school career, but must have doctor and parent signature. Required to make dietary changes in hot lunch program or milk changes.

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.

Seizure Emergency Care Plan:
This form should be completed for students that have a seizure disorder.

Diabetes Medical Management Plan (Dmmp) Aka Pediatric Diabetes Action Plan or provide plan from student's endocrinologist

These forms should be completed 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.

Asthma Action Plans:
Asthma Action Plans need to be completed for students with asthma. This form will give authorization for asthma medications to be given at school. Asthma Action Plans can be requested from your Health Care Provider. It is electronically signed by a physician and is good for a year from that signature date.

Authorization to Release Protected Health Information:
Please fill out one of the authorization forms so that the health office staff may communicate with your primary care providers/specialists to discuss health conditions as needed.

Goodhue Public Schools

Health Services

Student Health Services Staff

Alicia Slagle, BSN, RN Licensed School Nurse PreK - Grade 12 Email Alicia Slagle Office: 651-923-4447 Fax: 651-800-9228

Forms

Immunizations

Is Your Child Well Enough To Go To School?

Special Diet Statement

Notice for 504 Plans

Overnight Field Trips