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Forms for Education

The forms listed on this page are intended to be samples that can be adapted for states and Local Education Authorities (LEAs), usually school districts or charter schools. The Information Release Form (Utah Schools) (PDF Document 51 KB) is a sample form that is intended to serve as a consent form to accompany the Medical Home to School Summary Form (PDF Document 40 KB) when providers request evaluations or services from the school.

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Information & Support

For Parents and Patients

Medical Home to School Summary Form (PDF Document 40 KB)
Sample form to facilitate communication between health care providers and school professionals relating to health concerns that impact a student's education.

Information Release Form (Utah Schools) (PDF Document 51 KB)
Sample form for schools that authorizes the exchange of information between the student’s health care provider and school professionals as it relates to the diagnosis/condition listed.

Accommodating Children with Special Dietary Needs in the School Nutrition Programs (PDF Document 849 KB)
From the U.S. Department of Agriculture Food and Nutrition Service, this document provides information about modifying school meals for students with disabilities and other dietary requirements including food allergies. The document includes a sample Eating and Feeding Evaluation form (Figure 1, page 34) to be completed by the child's parent and physician and a sample Information Card (Figure 2, page 35) for use by school food service staff in preparing meals for the child.

Medication Administration Form (Utah) (Word Document 40 KB)
Sample form to be completed by the parent and medical provider to administer medications to students. From the Utah Schools for the Deaf and Blind.

School Contacts (Utah) (PDF Document 75 KB)
A sample page for recording school contact information such as the school nurse, administrators, etc., from a sample care notebook.

Building Your Care Notebook (AAP)
The American Academy of Pediatrics provides a central place with links to several forms from many states. For families that are new to making care notebooks, we suggest you pick one form and try filling it out before downloading other forms.

P.R.O. Filer Personal Portfolio & Filing System (PDF Document 160 KB)
P.R.O. filer - Personal Portfolio and Filing System (2000), an innovative tool designed by students for students that provides a way to organize important documents, keep records of school and community learning opportunities, and create a personal portfolio to showcase their accomplishments. Published by the Institute on Community Integration. See the companion Personal Portfolio Manual. For more tools, see the All Means All School-to-Work web site at http://ici.umn.edu/all/.

Personal Portfolio Manual (PDF Document 151 KB)
P.R.O. filer - Personal Portfolio and Filing System (2000), an innovative tool designed by students for students that provides a way to organize important documents, keep records of school and community learning opportunities, and create a personal portfolio to showcase their accomplishments. Published by the Institute on Community Integration. See the companion P.R.O. Filer Personal Portfolio & Filing System.

Authors

Author: Alfred Romeo, RN, PhD - 12/2014
Reviewing Author: Shena McAuliffe, MFA - 1/2015
Content Last Updated: 4/2015