Medical Plan Information
Plumbrook Elementary
Medical Plan information
Dear Plumbrook Parents,
Utica Community Schools is committed to providing a healthy and safe environment for each of our students. A health plan is required to be completed at the beginning of every school year. Health plans should be completed for any condition that may involve special dietary considerations, activity accommodations, medications or treatment of urgent problems. Completion of health plans allow our staff to take the best possible care of your child.
A physician signature is required on all health plans. Any medications that are to be distributed by school staff or used by your student at school must have an Authorization for Medication form completed and signed by a physician, including any over-the-counter medications.
Health Care Plans and Authorization for Medication forms are available at Resources and Forms - Utica Community Schools (uticak12.org). Depending on your child’s diagnosis, the following forms are required by the school:
· Food Allergies/Insect Allergies/Latex Allergies*
o FARE Food Allergy and Anaphylaxis Emergency Care Plan
o Michigan Department of Education Medical Statement to Request Special Meals and/or Accommodations (Special Diet Statement form),
o Two (2) Authorization for Medications (for an anti-histamine and for Epinephrine)
· MDE Dietary Accommodations (Special Diet Statement)
o Required for Food Services for students with Food Allergies or other health conditions requiring specific meal accommodations.
· Asthma*
o Asthma Health Care Plan
o Authorization for Medication for a rescue inhaler.
· Seizure*
o Seizure Health Care Plan
o Authorization for Medication for rescue medications and/or other medications.
· Diabetes*
o Diabetes Health Care Plan
o Diabetes Medical Management Plan from your Endocrinologist
· Heart Condition*
o Heart Condition Health Care Plan
· Any other diagnosis*
o General Health Care Plan
o Authorization for Medication if needed
* Two transportation forms, with a COLOR photograph of your child attached to each, is required for every student who rides a bus.
Please return all the necessary, completed and signed forms to your current building principal at your earliest convenience at their email: officeplumbrook@uticak12.org
Your cooperation will help ensure a safe and healthy school year. Any questions can be directed to the school nurse:
Tiffanie Polizzi, RN tiffanie.polizzi@uticak12.org 586-719-2793