Documents

Consent to Treat and Medication Administration Consent

MDS of Decatur Township's school clinics are staffed by trained Community Health Network medical professionals.  This is a school clinic, and not part of Community Health Network.  All records are maintained by the School.  There is no charge to you for the services.  Health services staff may provide non-emergency first aid treatment, emergency care, and conduct health screenings to students, without the return of this permission form.  To approve use of clinic records to determine eligibility for the student to participate in school activities, and for unlimited nursing services, please return this form as well as a Request to Administer Medication form if there is any medication to be administered to the student during the school day.  If your child has or needs a Plan of Care for recurring treatment, please also submit that information with this form.

Medication consent forms are necessary for any medication to be given by the school nurse during the school day.  A parent or legal guardian must complete the form for each medication.  The form will be kept on file in the school nurse clinic.  Prescription medications must be brought in with the current pharmacy label attached.  The nurse must follow the instructions on the prescription label. Over the counter medications must be in the original container.  The school nurse will follow the instructions on the label unless otherwise instructed by a health care provider's written order. 

• Consent to Treat
• Consent to Treat (Spanish)
• Medication Administration Consent Pre-K - 8th grade
• Medication Administration Consent 9th-12th grade
• Medication Administration Consent Pre-K - 8th grade (Spanish)
• Medication Administration Consent 9th-12th grade (Spanish)

Decatur Virtual Care Clinic

• Virtual Care Consent K-12th grade

Community Health Network Privacy Policy

• Notice of Privacy Form

Emergency Action Plans

If you have indicated that your child has a chronic health condition on the Emergency Medical form when registering your child, you will be asked to please have your health care provider fill out one of the following forms and return to your school nurse.  These should be updated at the beginning of each school year.  

Asthma Forms

• Asthma Action Plan

Diabetes Forms

• Diabetes Medical Management Plan

Food Allergy Forms

• Food Allergy Action Plan
• Mandatory Form for Food Allergy

Seizure Action Plan

• Diastat Care plan
• Seizure Action Plan

Other Allergy Forms

• Allergy Action Plan

Immunization Exemption Forms:

New forms must be turned in each year

*All exemptions must turn in this form: Medical or Religious Exemption plus one of the two forms below(Religious or Medical Exemption)

• Religious Immunization Exemption Form
• Medical Exemption for Immunization

Lice Information and Policy

• Head lice article
• Lice Guidelines