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532.1 Parental Identification of Student Irritant and/or Allergen Form

PARENTAL IDENTIFICATION OF STUDENT IRRITANT AND/OR ALLERGEN FORM

 

The undersigned(s) are the parent(s), guardian(s), or person(s) in charge of _______________________ (student’s full legal name), who is in the ______ grade at the _____________________________ building in the Central Decatur Community School District.

I am requesting that the above student should not be exposed to or should be minimally exposed to the following irritant(s) and/or allergen(s) because such irritant(s) and/or allergen(s) pose a risk to the student’s health and safety during the school day:  (Attach additional sheets if necessary):

 (a) Irritant and/or Allergen: _______________________________________________________

                                                                                                                            

      Why Requesting Limited Exposure (i.e., identified allergy, doctor’s request, other reason):  

      _________________________________________________________________________

      _________________________________________________________________________

       Possible Exposure Symptom(s):_______________________________________________

      _________________________________________________________________________

       Proposed Plan for Limiting Exposure: ___________________________________________

      _________________________________________________________________________

 Parental Authorization and Release Form for the Administration of Medication to Student:

_____ I have completed a Parental Authorization and Release Form for the Administration of Medication to Student so that the Central Decatur Community School District, or its authorized representative, may administer medicine to the above-named student in the case of exposure to an irritant or an allergic reaction.

-OR-

_____ I have NOT completed a Parental Authorization and Release Form for the Administration of Medication to Student, and do not intend to do such.

 Meeting with District Regarding Limiting Student Exposure to Irritant(s) and/or Allergen(s):

_____ I wish to request a meeting with the District to discuss the above student’s exposure to irritant(s) and/or allergen(s), and, if appropriate, develop a plan based on the student’s physician’s recommendation to limit the above student’s exposure to irritant(s) and/or allergen(s).

-OR-

_____ I DO NOT wish to request a meeting with the District to discuss the above student’s exposure to irritant(s) and/or allergen(s).

___________________________________                                                  _________________

(Signature of Parent/Guardian)                                                                      (Date)

 ___________________________________                                                  _________________

(Printed Name of Parent/Guardian)                                                               (Phone Number)