Medication Forms

Anaphylaxis Plan 

Allergy students need a health Care Plan signed but a doctor and their Epi-Pen/Benadryl in a sealed box with a prescription label and current expiration date.

Asthma Care Plan 

Asthma students need a Health Care Plan signed by a doctor and their inhaler in a sealed box with a prescription label and current expiration date.

Medication Agreement Log

Health Care Provider Signed Order For Medication

Please be sure to complete both the Medication Agreement Log & the Health Care Provider Signed Order for Medication.

For the 2018-2019 school year families will need to fill out a Medication Agreement form for all non-prescription medication (over the counter, example, cough drops, Ibuprofen, Tylenol, etc.) and returned to Sheridan Green Elementary. You will need to bring in a completed form along with the medication in an original container (no baggies).  If the medication is expired the school is not allowed to accept it in the clinic.  If it is a prescription medication from a doctor, the doctor’s portion must be filled out, signed, and dated.  The parent portion must also be filled out and signed.  A prescription label must be attached to the original container.  



If you have any questions please contact:

Mrs. Price

Health Aide



Fax- 303.982.3183

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