• ResourcesHealth Forms/Medication

    FORMS MUST BE COMPLETED ANNUALLY AND ARE VALID THROUGH THE CURRENT SCHOOL YEAR INCLUDING SUMMER SCHOOL.

Allergy Management

This form packet is for students diagnosed with ALLERGIES.  Fremont Unified School District must comply with California Education Codes and District Policies when providing Epinephrine Auto-Injector administration for students.  These services can only be provided after the appropriate forms are received, a healthcare plan is written, and staff training is complete. 

Allergy Management Form Packet Current Year 2017-2018 (zip file of 6 .pdf documents 844k)


Seizure Management

These forms packet are for students diagnosed with a seizure disorder.  Fremont Unified School District must comply with California Education Codes and District Policies when providing SPHC (Specialized Physical Healthcare Services).  These services can only be provided after the appropriate forms are received, a healthcare plan is written, and staff training is complete. If student does not have an individualized seizure plan designated by the physician, 911 will be called immediately if the student has a seizure.

Seizure Management Form Packet Current Year 2017-2018 (zip file of 6 .pdf documents 815k)


Diabetes Management

This form packet is for students diagnosed with DIABETES.  Fremont Unified School District must comply with California Education Codes and District Policies when providing SPHC (Specialized Physical Healthcare Services) such as blood glucose testing or insulin administration.  SPCH services can only be provided after the PARENT/GUARDIAN CONSENT FOR MANAGEMENT OF DIABETES AT SCHOOL and HEALTH CARE PROVIDERS ORDERS are received, a healthcare plan is written, and staff training is complete. 

Diabetes Management Form Packet Current Year 2017-2018 (zip file of 3 .pdf documents 263k)


Specialized Health Procedures

This form packet is for students who require a Specialized Physical Health Care (SPHC) procedure at school such catheterization, nebulizer, or tube feeding.  Fremont Unified School District must comply with California Education Codes and District Policies when providing SPHC. These services can only be provided after SPHC FORM A is received, a healthcare plan is written, and staff training is complete. 

SPHC FORM A - Specialized Health Procedures Packet Current Year 2017-2018 (zip file of 6 .pdf documents 832k)


Supplemental Forms
(Medication at School, Self Administration Contract, Request for School Activity Restrictions, Release to Display Student Photograph)

REQUEST FOR SCHOOL ACTIVITY RESTRICTIONS/LIMITATIONS (pdf)
This form is for students with short or long-term health conditions which limit full participation in the required physical education program. This form can also be used to clear a student to return to full participation in the physical education program.

FORM D/MEDICATION AT SCHOOL (pdf)
This form is required for school personnel to assist with administration of medication at school or if student will self-administer or carry medication. This form applies to “over-the-counter” and prescription medications. Examples include but are not limited to Albuterol inhaler, Tylenol, ADHD medication. FORM E is also required if student is authorized to self-administer or carry medication.

FORM E/SELF ADMINISTRATION OF MEDICATION CONTRACT (pdf)
This form is required in addition to FORM D if student will self-administer or carry medication. FORM E is signed by the student and parent.

FORM C/RELEASE TO DISPLAY STUDENT PHOTOGRAPH (pdf)
This form is optional and allows a photograph of your student to be included with the healthcare plan for the purpose of physically identifying him/her. Parent/guardian must supply a current photo attached to this form.