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504.5E1 Student Exposure to Irritants and Allergens Form

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 Columbus 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 Columbus 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)

 

Approved: 10/16/14
Reviewed: FY 2015-2016, March 14, 2016,  May 24,2021
Revised: 02/24/17