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Medical Forms

Families must complete the required forms and have them signed by their healthcare provider if their student has a condition that requires the administration of any medication during the school day.

To fill out any of the forms below:

  1. Click on the form link.

  2. Download the form.

  3. Print the form.

  4. Fill out the form.

Medication Forms

Families must provide a Medication Agreement form, completed and signed by their healthcare provider if their student has a condition that requires the administration of any medication during the school day. This includes over-the-counter and prescription medications.

Families will provide medication in the original packaged or prescription container that has not expired with the signed medication form below. Once received, a nurse may delegate administration of a prescription or over-the-counter medication, based on the health care provider's order.

According to Board policy JLC and Colorado Nursing Board Policy #30-04, district nurses must call physicians to verify orders if needed.

Medication agreement form

Medication Agreement (English) Acuerdo de medicación (Spanish) Разрешение на выдачу лекарств (Russian)

Extended field trip medication forms

One of the following forms must be completed for any overnight field trip.

CO State Asthma Care Plan

Students who require an inhaler or medication for asthma need their healthcare provider and families to complete the Colorado Asthma Care Plan and return it to the school health aide with the medication. 

This form replaces the medication agreement form. Families of students with asthma or health concerns are encouraged to contact their District Registered Nurse (RN) to follow up regarding care and support at school.

Asthma Care Plan Form

CO State Allergy Care Plan

Many students have potentially life-threatening food allergies. To address this issue and meet state law requirements concerning managing food allergies and anaphylaxis among students, the Board has established Policy JLCDA. This policy specifies details about a health care plan, reasonable accommodations, access to emergency medications and staff training.

Families, the school administrator, and the District RN will develop a health plan using the Colorado Allergy and Anaphylaxis Care Plan, which you can have your care provider complete and return to the school. This form replaces the above medication agreement form.

Allergy Care Plan Form

Jeffco Allergy Handbook

CO State Seizure Care Plan

In 2021, the Colorado General Assembly passed HB-21-113 to prioritize school safety for students who have a seizure disorder, including epilepsy. This bill addresses strategic resources for kindergarten through 12th-grade schools to provide a safer environment for these students, including school personnel training, individualized seizure action plans and seizure care guidelines. 

Your District RN will work with you to develop a health plan using the Colorado Seizure Care Plan which you can have your provider complete and return to the school. This form replaces the above medication agreement form.

Seizure Care Plan Form

Contact Us

Health Services

Email: healthsvcs@jeffco.k12.co.us
Phone: 303-982-7251
Fax: 303-982-6676