Forms

Some of these forms can be completed on line, saved, and then attached to an email (see contact information).  Other forms must be then may be scanned and emailed, faxed, or mailed.


Anaphylaxis 
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Go to Life-Threatening Health Conditions (scroll down) 

Diet Prescription for Meals at School
Health-care provider must complete and sign that the student needs special school meals prepared or served because of the student's disability or chronic medical condition. 
    Field Trip/Outdoor Education Information and Release
    Emergency contact information, medical concerns, and authorization to receive emergency medical or dental care while away from the school.  Must be signed by a parent or guardian. Health Registration Form  - revised 8/2014
    Information provided by a parent/guardian giving emergency contact information and alerting the school nurse to health issues.  This form may be requested by the school each school year in order to keep current with your child's health information.
    HIV / AIDS Education Home/Hospital Instruction - return to top
    • Home / Hospital Instruction - is a state (OSPI) program that provides funding for schools to provide limited scholastic support to students with a health issue. To qualify, students must be expected to miss at least four (4) weeks of school, but no more than eighteen (18) weeks. In case of chronic illness, the services can be intermittent (Please indicate this on the application form). The form must be signed by the parent/guardian and the health care provider.
    • Pregnancy and Postpartum - the "usual and customary" weeks of postpartum service are six (6) for a routine vaginal delivery and eight (8) for a c-section. Please do not exceed those numbers without indicating a reason the student is unable to attend classes because of her own medical needs.
    • Please note that Health Services merely verifies the student’s eligibility for services and serves as a pass through for funding from OSPI.  The school is responsible for finding a tutor and setting up the educational plan.
    • There are strict requirements for reimbursement from OSPI for this funding so if/when the request is approved, please read the instructions carefully as  we cannot fund services until H/H is approved.  Buildings will be responsible for any expenses incurred beyond the limits of the program.
    • Special Education Students - IMPORTANT: If a student cannot attend school because of a need related to his/her qualifying special education condition, do not submit a Home/Hospital application until after contacting the school's Section 504 coordinator and the IEP responsible staff for that student.  Special Education manages funding for IDEA students who require Home Hospital support.
    Immunization-
    Click Here for more information on immunizations.

    Level B Schools for 16-17 School Year
      Life-Threatening Health Conditions (Health Packet)
      Washington State law requires that when there is a student with a known life-threatening condition schools must be prepared for a life-threatening event on the day the student starts school.  This would include the necessary forms from the health care provider as well as any needed medications. These documents need to provide current information so should be prepared after July 1 for the following school year! 

      Please be sure you have completed the following forms and bring medication(s) to school if your student has a know life-threatening condition: 

      Medication at School - revised June 2015
      State or federal law requires that a form must be completed and signed by both parent/guardian and a licensed health care provider with prescriptive authority for ALL medications to be given at school, including over-the-counter (OTC) medications.  See Health-Related School Information for more detail.  This form needs to be renewed at the beginning of each school year.
      • English - revised June 2015, translations coming soon! Please use this one if you are able.
      Mutual Exchange - revised 11/30/09
      Gives Seattle Public Schools and a health care provider, hospital, or clinic permission to exchange information about a student. Too Sick for School
      This will help you determine if your child is too sick to go to school.

      Transportation for Medical Reasons
      For students who are within the walk zone but who have a medical condition that makes transportation necessary.  May be for short-term or long-term conditions.

      Application must be renewed annually.

      Cannot be used to serve special education students for conditions related to their qualifying condition.  Contact Special Education in those cases. Treatment and Procedure Authorization Gives permission for an authorized person to assist a student by performing a specific treatment or procedure.

       

      Contact Us

      General Inquiries
      Fallen Kongsaeng
      Fakongsaeng@seattleschools.org
      T 206-252-0750
      F 206-252-0751

      Interim Health Services Manager
      Marie DeBell
      mdebell@seattleschools.org
      T 206-252-0079
      F 206-252-0751

      Quick Links

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