Seizures
Anson Independent School District
Health Services Department Place Student Label Here

Parent/Guardian(s)-

In order for school personnel to provide treatment for any physician diagnosed

medical condition, new authorization must be given and on file in the school clinic

and/or office annually.

If you do not want treatment provided and/or medications administered by Anson ISD personnel or if your child no longer needs this service, please complete the

“Waiver of Treatment” form attached to this letter and return to school clinic or

office.

The Seizure Action Plan and the Parent/Physician Authorization forms (attached) must be completed as follows:

  • Completed and signed by student’s physician
  • Parent read and signature
  • Return to nurse’s office

Each student that has a seizure action plan must also have an Emergency Contact

Information and Consent (attached) on file in the nurse’s office.

  • This information is to be provided by the parent/guardian, including the parent/guardian(s) signature.

All medications and/or supplies will need to be:

  • In original container with prescription label attached
  • Delivered to school by parent/guardian
  • Medications and/or supplies need to be placed in storage (Ziplock® type) bag with student’s name placed on outside.
  • Picked up on or before the final day of class.
  • All unclaimed medications will be discarded at the end of the school year.
  • There will be NO medications kept in the clinic through the summer months.

All required documentation will be kept on file and must be renewed annually.

Authorization forms are available on line at or at the nurse’s office.

Please advise school at any time throughout the year if there are

  • any changes in the information about your child’s health care needs

Thank you,

Michelle Huffaker, RN

Anson ISD Health Services Department

Seizures – Emergency Action Plan
Physician’s Orders
Anson Independent School District

To be Completed by Physician

Seizure Type:
□ Absence – Staring & decrease in responsiveness □ Simple Partial ______□ Complex Partial ______□ Generalized Tonic-Clonic ______□ Tonic ______□ Drop ______□ Other ______
Seizure Medication:
□ No medication at school – Current medication at home ______□ Oral medication at school ______Dose ______Frequency ______
______Dose ______Frequency ______
Seizure Emergency Medication:
  • For a ______seizure lasting longer than ______minutes OR
  • For more than ______seizures within ______minutes –
ADMINISTER: ______Dose ______Frequency ______
______
CALL 911 if: ______
______
Safety Precautions/Activity Restrictions: ______
______
______
Other: ______
______

______

Physician’s SignatureDate

______

Printed NamePhone Number

______

Name of Practice (Clinic)Fax Number

______

Parent SignatureDate

Seizures – Emergency Action Plan
Information/Authorization
Anson Independent School District

To be completed by Parent/Guardian

Seizure First Aid:
Note time when seizure starts and ends Note body parts involved Call School Nurse
Keep Safe Remove hard objects Do Not Restrain
Do Not put objects or food in mouth Place in a side-lying position Provide Privacy - as possible
Stay with student until student has fully recovered Re-orient student to activity
Parent/Guardian Authorization:
  • I agree with the attached Seizure – Emergency Action Plan and I request that the above medication(s) be given during school hours as ordered by my child’s physician. □ yes □ no □ not applicable
  • I request that the above medication be sent on field trips □ yes □ no □ not applicable
  • I will notify the school if medication is stopped □ yes □ no □ not applicable
  • I give permission for the medication(s) to be given by school personnel as delegated, trained and/or supervised by the licensed school nurse. □ yes □ no □ not applicable
  • Legally I may refuse to sign the Seizure Emergency Action Plan. If I refuse to sign, I understand that the district will not be able to administer the prescription medication.
______
Parent Signature Date
Permission for Release of Information
  • I give permission for the school nurse to communicate, as needed with school staff about my child’s medical condition(s) and the action of the medication(s)
  • I give permission for the licensed school nurse to contact my child’s physician and/or other licensed provider regarding questions about the above listed medication(s) and/or medical condition(s) being treated by medication(s)
______
Parent Signature Date
Emergency Contact Information
and Consent
Anson Independent School District

Student Food Allergies: ______

______

______

Student Medication Allergies: ______

______

______

Grade: ______Male: ______Female: ______Date of Birth: ______

Address: ______Home Phone: ______

______Cell Phone: ______

______Emergency No.: ______

Father’s Name: ______Work Phone: ______Cell Phone ______

Mother’s Name: ______Work Phone: ______Cell Phone ______

In case parents cannot be reached at time of emergency, please call:

Name: ______Home Phone: ______

Relationship to student: ______Cell Phone: ______

Name: ______Home Phone: ______

Relationship to student: ______Cell Phone: ______

Name: ______Home Phone: ______

Relationship to student: ______Cell Phone: ______

Unfortunately, there is always the possibility of an accident occurring to a student at school or while participating

in an after-school activity. In case an accident should occur, the school and/or the UIL does not assume

responsibility. Nevertheless, if an accident should occur, a discretionary judgment will be made by a school representative in regard to the student’s need for immediate care and treatment. Therefore, I do herby request, authorize, and consent to such care and treatment as may be given to the said student by and physician, trainer,

nurse or school representative. As well, I do hereby agree to indemnify and save harmless the school and any

school representative from any claim by any person whomsoever on account of such care and treatment of the

said student.

Between this date and the end of the school year, illness or injury could occur that may limit the student’s participation, I agree to notify the school authorities of such illness or injury.

______

Signature of Parent/Guardian Date

______

Signature of Parent/GuardianDate

Diagnosed Medical Condition
Waiver of Treatment
Anson Independent School District

My child, ______has been medically diagnosed and/or treated

for Seizures and I have been informed by Anson ISD, school personnel of the required

documentation needed to properly treat him / her while at school and/or school related events. I understand that it is my responsibility to provide to the school all needed information and

medication. However, I decline to participate in the requirements. Therefore, I do herby agree

to indemnify and save harmless the Anson ISD and any of its representatives from any liability

arising in the event that my child, listed above, have an seizure and/or seizure-like related episode.

______

Parent SignatureDate

______

Parent Printed NamePhone Number