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 South Tama County 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 South Tama County 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 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)
(August 19, 2019)