School Entry

Health History – English Version
For all students in Pk/kindergarten, fifth grade, ninth grade, new to ASD and students with health concerns Hmong | Korean | Samoan | Spanish | Tagalog

Parents are encouraged to call or visit their school nurse and talk about the special needs of their child. This is especially critical for students with special medical conditions or when there has been a significant change in a child's health. 

 

Physical Examination for School Entry – English Version
For all New-To-District students (Preschool through 12th grade) Hmong | Korean | Samoan | Spanish | Tagalog

 

PPD Tuberculin Skin Test Risk Assessment Consent – English Version
For all New-To-District students (Preschool through 12th grade) or students who have returned to the Anchorage School District after a two year and one day absence. Hmong | Korean | Samoan | Spanish | Tagalog


Medication-Related Forms

Long Term Non-Prescription Medication Request
Parent permission form for requesting the district give non-prescription medicine under certain conditions. Use this form for the current school year for any non-herbal, non-homeopathic medications that can be purchased at a store.

 

Long Term Request for Administration of Prescribed Medication
This form or a written statement signed and dated by the health care provider (MD, DO, ANP, PA) is required for medication prescribed for more than 15 days during the current school year. Renewed yearly.

 

Self-Carry/Administration of Medicine Authorization for After-School Activities
Parent permission form allowing for a responsible, trained student to carry and/or self administer prescription labeled medication for asthma, severe allergic (anaphylactic) reaction, or diabetes. (Self carry authorization is part of Asthma and Allergy/Anaphylaxis plan for during school time)

 

Short Term Prescription Medication Request
Parent permission form for allowing school personnel to administer health care provider prescribed short-term prescription medicines for a period of time not to exceed 15 days. A current pharmacy label on the container will be accepted as the legal prescriber's authorization for short term medications.

 

Short Term Medication Request for Out of District Travel - Elementary students
Parent permission form for requesting school personnel to assist students or parents of students whose health care provider has prescribed short-term medicines not to exceed the duration of a trip.

 

Short Term Medication Request for Out of District Travel - Secondary students
Parent permission form for requesting school personnel to assist students or parents of students whose health care provider has prescribed short-term medicines not to exceed the duration of a trip.


Action Plans/Accommodations

Allergy Anaphylaxis Action Plan
For students with allergy/anaphylaxis medication in school (parent and physician to complete)

 

Asthma Action Plan
For students with asthma medication in school (parent and physician to complete)

 

Diabetes Injection/Pump Careplan for School
For student with diabetes medication/injection/insulin pump in school (parent, nurse and physician to complete)

 

Continuous Glucose Monitor Addendum/Guidelines

For student with diabetes using Continuous Glucose Monitor Addenda.

 

Diabetes Care for Out-of-school-Hours Activity Addendum

For student with diabetes during Out-of-School-Hours Activities Health Plan Addenda.

 

Seizure Action Plan

For student with seizure medication in school (parent and physician to complete)

 

Special Meal or Accommodations Request - A-7 form
For students requiring special dietary needs (parent and physician or recognized Medical Authority to complete)

 

Special Nursing Services/Treatments (i.e. Gastrostomy feeding, catheterization, nebulizer, oxygen, etc.)

Parent/Guardian Request for Special Nursing Service
For parents to request special nursing care service for their child and procedure is necessary for child to attend school and cannot be provided before or after school hours.

 

Physician’s Authorization Special Nursing Services
Required form for parents requesting special nursing care or treatments for their child (physician to complete)


Request for Release of Records

Authorization for Release of Immunization/TB Records
Alaska Department of Health and Social Services' authorization to release immunization and/or TB records from another provider to Anchorage School District

 

Consent for Release of Health Information

Authorization for use or disclosure of health information between medical providers and school district

 

Consent for Release of Education Records 

Authorization for use or disclosure of education records


Sports Physical

Health Exam Sports Physical Form A
For all students requiring sports physical examination

 


Accessibility
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