508.6E1 - 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 Red Oak 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 Red Oak 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)