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