Health Forms
This page has been developed so you may quickly access the necessary health forms used at Wesleyan Christian Academy. Before filling out any forms regarding medications to be used at school, please make sure and read the School Medication Policy.
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All New Students: All new students must complete a Health & Emergency Information form. Please open this form, and fill it out. This form cannot be saved to your computer - you must print it out when finished, sign it and then FAX, mail or deliver to the school office. The FAX number is at the top of the form.
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If your child requires an emergency action plan of any kind, please contact me so we can discuss the health needs of your child.
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Asthma Action Plan – If your child has asthma, please have your healthcare provider complete an Asthma Action Plan. Responsible students in grades 5 and above may carry inhalers if a Student Contract for Self-Carried Medication/Equipment form is completed as well as the Asthma Action Plan. Both forms must be signed by the healthcare provider.
Anaphylaxis/Severe Allergy Emergency Action Plan – If your child has severe food or bee sting allergies requiring medication intervention, please have your healthcare provider complete an Anaphylaxis/Severe Allergy Emergency Action Plan. Students who require emergency epinephrine (Epi-Pen), and demonstrate proficiency in its use, may carry their own injector. A Student Contract for Self-Carried Medication/Equipment form must be completed in addition to the anaphylaxis form. Forms must be signed by the healthcare provider.
Cystic Fibrosis Individualized Health Plan -- If your child has Cystic Fibrosis, please have this form filled out.
Authorization for Medication Administration - Taking medication at school should be avoided if possible. Please time doses before and after school hours whenever possible. In the event it is necessary to give medication during school hours, please make sure you read and understand the School Medication Policy; and then have your healthcare provider complete this form. This applies to both prescription and over-the-counter (OTC) medications.
Health & Emergency Information – This form must be completed by all new students. At the beginning of the school year, returning students will receive a completed form based on the information provided during reenrollment. The information should be reviewed for necessary changes and then signed and returned to school.
School Medication Policy – This document should be read prior to filling out any forms authorizing a student to receive medication during school hours.
Student Contract for Self-Carried Medication/Equipment – Responsible students in grades 5 through 12 may self-carry and administer emergency medications (inhalers, epinephrine) if this form is filled out in conjunction with the Authorization for Medication Administration form. These forms must be signed by a healthcare provider. The school nurse may approve other medications under special circumstances.
Seizure Action Plan: If your child has a seizure disorder, please have your healthcare provider complete a Seizure Action Plan (link). Having an Action Plan in place helps us quickly and safely respond to your child’s needs.
Diabetes – If you child has diabetes, please send a copy of your healthcare provider’s or diabetic educator’s Emergency Action Plan. If they do not have a form, please contact me.
Other Health Conditions - If your child has a health condition not mentioned above, that might require emergency intervention, please contact me so we may develop an individual care plan that meets the needs of your child.