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 Spirit Lake 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 Spirit Lake 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.
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Approved: 1/13/20 |
Reviewed: |
Revised: |