PWCS Health Forms

Below are downloadable forms. If your child has a health concern that will/may need to be addressed during school hours, please complete the appropriate forms. As a reminder, Health Treatment Plans (HTPs) need to be re-done annually (by both parent and health care provider) and should be brought to the clinic with any medications prior to the beginning of each school year. Students may not bring medication to or from school at any time without proper parental and physician consent on file in the school clinic (updated annually).

Health Forms and Regulations

• Medication Administration at School Regulation 757-4

• School Entrance Health Form-- Complete this if your child is new to PWCS. Also, be sure to get all his/her immunizations up-to-date and bring a record. A tuberculosis screening may be required, and your health care provider can assist you with this if needed.
  
  
• Medication Administration Authorization Form-- Complete  if your child requires a medication at school. If you have questions, please consult with school nurse.

ASTHMA

• Asthma in the School Setting Regualtion 757-3

• Asthma Action Plan - Virginia Asthma Action Plan--Complete this if your child has asthma.

ALLERGIES

• Allergic reactions in the school setting Regulation 757-2

• Student Allergy History Form

• Food Allergy & Anaphylaxis Emergency Care Plan

• Request for Administration of Medication for Allergic Reactions

• Student Ephinephrine Self Carry Authorization

• Severe Allergy Individual Health Care Plan

EPILEPSY

• Epileptic seizures in the School Setting Regulation 757-7

• Seizure Action Plan Part 1 – Part 2-- Complete these 2 parts if your child has a seizure disorder.
  
  

DIABETES

• Management of Diabetes in School Regulation 757-6

• Diabetes Medical Management Plan-- Complete this DMMP if your child has diabetes and contact the School Nurse prior to the child coming to school to go over the plan.
  
  
• Diabetes - Students with Insulin Pump and/or Continuous Glucose Monitors usage at school guidance

HEALTH/EMERGENCY TREATMENT PLANS

• Management of Students with Health Treatment Plans Regulation 757-3 The following are for the treatment and/or procedures that cannot be managed with the Health Treatment Plans listed above.
• Authorization to Implement Health Treatment Plans

• PWCS Clean Intermittent Catherization
• Tube Feeding
• Authorization for Specific Medical Procedure
• Authorization and Consent for Exchange & Release of Medical Information