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Spencerville Local Schools

Medical Forms

Attached forms:

1)    Medication Authorization Form - K-12

It is recommended that medication be given at home, but if this is not possible, school personnel (school nurse or employees designated by school policy) may administer medications if the following requirements are met:

  • This form must be completed for each medication whether it is for a prescription or over-the-counter medication such as Tylenol. Parental signature is required for both prescribed and non-prescribed medications. A physician's signature is required for all prescription medication. Aspirin is not recommended for school age children and will not be given at school unless ordered by a physician.
  • Prescription medication must be dropped off  at the school by a parent, guardian, or other authorized adult along with the completed medication authorization form the day the child is to start taking the medication. The medication will be logged in on a Medication Inventory Record.
  • The medication is delivered to the school in the original labeled container in which it was dispensed by the prescribing physician, licensed pharmacist, or manufacturer. Give to secretary or school nurse.
  • A written physician's statement or new form is needed if any of the required medication information should change.

2)    Authorization for Student Possession & Use of An Asthma Inhaler - Complete this form if your child needs to carry an inhaler at school.  Turn completed form into the school nurse at beginning of each school year.

3)    Authorization for Student Possession & Use of An Epinephrine Autoinjector - Complete this form if your child needs to keep an Epipen or Epinephrine Autoinjector prescribed for school (will be keeping in his/her possession at school or storing in clinic at school). Turn completed form into the school nurse at beginning of each school year.

4)    School Policy on Communicable Diseases - Find out when your child is considered contagious and should be excluded from school.

5)   Immunization Requirements for K-12 School Attendance - Check the Ohio Department of Health’s requirements for immunizations and school entry for Kindergarteners, 7th graders, 12th graders, and students new to the district.

6)     Requirement for all 7th graders to obtain a Tdap booster and a Meningococcal Vaccine by the first day of school.

  • A Tetanus-Diphtheria-Pertussis (Tdap) shot is required for all 7th grade students. If one dose of Tdap was part of the initial series, another dose of Tdap will not be required. Tdap can be given regardless of the interval since the last tetanus - or diphtheria-toxoid containing vaccine.
  • A meningococcal vaccine is required for all 7th graders.
  • Once your child receives the shots, please send in documentation to the school nurse so the health record can be updated. Attached is the Tdap & Meningococcal Vaccine Information Sheets from the CDC.

7) Requirement for all 12th graders to obtain a Meningococcal vaccine by the first day of school.

8) Birth Certificate Requirement -A copy of the official birth certificate issued from the health department in the county in which the child was born is required for all kindergarteners and any student new to the district in grades 1-12. Hospital birth certificates are no longer accepted.

9) Eye Exam Requirements for Special Education Students

Amended Substitute House Bill 95 passed in 2003 requires students initially identified with disabilities to have a comprehensive eye exam from an eye doctor. If the student had an eye exam during the previous nine months, this requirement is waived. If you do not have insurance, the exam will be provided for free. See the following attached forms:

10)  Health Partners of Western Ohio Dental Program - If interested in having your child seen at Spencerville Schools by Health Partners dental team, please contact the school nurse for an application. They will see consenting K-12 students in April/May to perform examinations, cleanings, fluoride treatments, and sealants.  Medicaid and private insurance companies will be billed by Health Partners, and there will be no out of pocket expense if there is no dental coverage.

It is recommended that every child be seen by a dentist 2 times per year. Prevention is less painful than treatment!

Student Accident Insurance