MEDICAL CONDITIONS

Do you have a Child with a Special Consideration...

Contact Heidi Yoklavich, R.N., District School Nurse at 435-637-3671

Per district policy and Utah State Laws, certain forms are required:

MEDICAL CONDITION

REQUIREMENT

DIABETES

Diabetes Medication Management Order (DMMO)

  • This form may be provided digitally by physicians per parent request. Please contact the individual school for the email and/or fax number to send it to.


Diabetes Individualized Health Plan (IHP)

  • This form is to be completed in collaboration with the parent and the school nurse.

  • Diabetes CGM Addendum to the IHP is needed if the student uses a continuous glucose monitor. 


Diabetes Emergency Action Plan (EAP)

  • This form is to be completed in collaboration with the parent and the school nurse. 

ASTHMA

Asthma Action Plan with Medication Authorization Form

  • This form is used if the student requires intense monitoring or support due to their asthma condition, and required if the student uses an inhaler while at school.

Asthma Medication Authorization Form

  • This form is required for students without a State Asthma Action Plan, and there is a request for the student to possess and self-administer asthma medication. The form is not valid without parent and prescriber signatures. 

FOOD ALLERGIES

Allergy and Anaphylaxis Health Plan and Ephinephrine Authorization

  • This form is not valid without parent and prescriber signatures.

SEIZURES

Seizure Health Plan 

  • This form is required for students who are currently experiencing seizures. 

Seizure Medication Management Order (SMMO)

  • This form is required if the student has seizure rescue medication ordered. The form is not valid without parent and prescriber signatures. 

OR

STUDENT NEEDS MEDICATIONS WHILE ATTENDING SCHOOL

Med-Tylenol Authorization Form

  • This form is not valid without parent and prescriber signatures.

Medication Authorization Form

  • This form is required for any medications other than Tylenol that have to be administered while a child is at school. The form is not valid without parent and prescriber signatures. 

STUDENT NEEDS A SPECIAL DIET WHILE ATTENDING SCHOOL

Special Meal Request Form

  • This form is not valid without parent and prescriber signatures. 

THE REQUIRED FORMS ARE ALSO LOCATED AT THE BOTTOM OF THIS PAGE UNDER RESOURCES 

  • Download the form(s)

  • Parents need to fill out the form(s)

  • Signatures of a parent and physician are required

  • Provide the form(s) to the school

IMMUNIZATION REQUIREMENTS

Access the Utah Department of Health's website outlining the required immunizations by clicking this link: School Immunization Requirement

  • Please keep in mind that immunization requirements apply to all incoming kindergarten and seventh grade students.  Students that are new to the district will also need to be current on immunizations. Information will be provided upon registration. 

Information to complete an exemption for immunization may be accessed on the Utah Department of Health: Immunization Program website. Follow the directions under Online Immunization Education Module. 

  • PLEASE NOTE: Immunization exemption must be completed at kindergarten and again at seventh grade. 

  • When the education module is completed, an exemption certificate will be emailed. The certificate must be provided to the school. 

Resources