Health & Medication Forms

Certificate of Immunization Status (CIS)
Washington State form used by parent/guardian to report immunization information for their student. See Washington State requirements for school attendance.  Some students (e.g., kindergarten, 6th grade) may need to complete the immunization requirements after registration and before the start of school.

Certificate of Exemption (COE)
Exemptions require both parent/guardian and health-care provider's signature except for certain religious exemptions.

Health Registration
Information provided by the parent/guardian 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.

Mutual Exchange of Information
Gives Steilacoom Historical School District and health care provider, hospital, or clinic permission to exchange information about a student

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. This form needs to be renewed at the beginning of each year. 

Medication at School (Form E)

Overnight Field Trip Medication at School 

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 needed medications.  These documents need to provide current information and should be labeled with the intended school year or be prepared after the last day of the previous year.

Epi Pen Request and Treatment Plan (Form D)

Asthma Medication and Treatment Plan (Form C)

Seizure Action Plan (Form B)

Health-care provider must complete and sign that the Feeding Tube Procedure Request at School.

Feeding Tube Order Set (Form F)

Health-care provider must complete and sign that the student needs a special school meals prepared or served because of the student's disability or chronic medical condition.

Dietary Request for a Student with a Disability  

Dietary Request for Student without a Disability

Please call the Lead Nurse, Emily Hofbauer (253-983-2223) to discuss the needs of your student. These documents need to provide current information and should be labeled with the intended school year or be prepared after the last day of the previous school year.

Health Care Provider Orders (Form A)

Health Care Provider Orders for Students with Insulin Pumps (Form G)

Parent Designated Adult Information