Emergency Care Plan & Health Room Forms

If your student requires a care plan and/or medication administration orders, these must be in place prior to school starting in September. The goal of the Lake Stevens School District is to support your child while at school, and ensure that your child is in a safe and healthy environment.

Please review the enclosed information carefully as it details our policies and procedures, some of which may have changed.

Emergency Care Plans

Legal Requirements

RCW 28A.210.320 requires all students who have a life-threatening health condition (who may require medical services be performed at school) to have a medical treatment plan or medication orders on file with the school. Under this law, children without the appropriate order would be excluded from attending school until the necessary documentation is received and reviewed by the school RN. Schools are to be prepared for a life-threatening event on the very first day of school. Conditions that are deemed potentially life threatening may include, but are not limited to, the following:

Allergy requiring Epi-pen use
Asthma with an allergy and/or Asthma requiring medication (inhaler or nebulizer) at school
Dysphagia
Seizures
Diabetes
Certain cardiac conditions

This law means that you must have health care provider orders completed, fill the prescription, and take all the supplies and paperwork to school before the first day the child attends. Each fall, the orders and plans must be updated for your student.

Obtaining forms

The forms required for the upcoming school year can be obtained through your school nurse. Please contact your child’s health care provider to complete the forms which will require yours and the provider’s signatures.

Please have the provider complete a medication authorization for each medication needed, which may include over-the-counter medications. If you and your child’s medical provider determine that a care plan is no longer needed, we must have written documentation signed by you and the provider.

Once you have the forms completed, please make an appointment to meet with the nurse at your child’s school to ensure that an appropriate care plan is created and in place. It is imperative that this paperwork be completed and returned promptly. Your child’s opportunity to remain in attendance at school will be in jeopardy unless this information is provided by the first day of school.

Students requiring emergency medication at school to treat a life-threatening health condition must adhere to District Policy No. 5475.2. Written authorization signed by the parent and licensed medical provider who prescribed the medication must be on file with the school nurse. Medication must also be in the original prescriptive container and labeled appropriately. Students failing to adhere to District medication policy number 5475.2 will be in violation of the school drug policy as outlined in the student handbook.

If your child is authorized by a physician to carry emergency medication on their person, we request that you provide additional medication to be stored in the Health Room in the event of an emergency.

Working together with you and your health care provider will ensure your student can attend school in a safe and welcoming environment. Thank you for your attention to this important matter.

Life-Threatening Food Allergy

If your child has a life-threatening food allergy, please see the information detailed above for "Legal Requirements." You can work with your school nurse to obtain the necessary forms. You may also access these forms using the links provided below; you will need to complete the "G3: Student Food Allergy Assessment Form" and the "G1: Severe Allergy Medication Order" form, which requires the signature of a Licensed Healthcare Practitioner (LHP).

These completed forms must be turned in to your school nurse, who will send a copy to Food and Nutrition Services where an alert will be entered on your student's lunch account. These forms are not optional and will be required if your student has a severe food allergy.

Anaphylactic Allergy Forms

Asthma Forms

Dysphagia Forms

Seizure Forms

Hemophilia Forms

Diabetes Forms

Cardiac Forms

Health Room Forms

Authorization for Administration of Medication

Student Health History

Non-Life Threatening

If your child has a NON-life threatening allergy or special dietary restriction AND you would like accommodations to be made by Food and Nutrition Services, you can work with your school nurse to obtain the necessary forms. You may also access these forms using the links provided below; you will need to complete the "G3: Student Food Allergy Assessment Form" and the "C6: Special Dietary Accommodations Request" form, which requires the signature of a State-Recognized Medical Authority.

These completed forms must be turned into your school nurse, who will forward any pertinent information to Food and Nutrition Services where an alert can be entered on your student's lunch account.