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Health Forms

***If your child is new to Roosevelt and has a health condition, or if your current Roosevelt student has developed a new health condition that we are not aware of yet, please contact Mrs. Serazio jserazio2@livoniapublicschools.org as soon as possible before the first day of school.  

Dear Families,

Please download the forms your child needs for school, based on their health conditions.  New forms must be completed by you and your child’s physician each year (dated after the last day of school of the previous school year).  Please ensure that the forms include both your signature and your child’s doctor’s signature.  We cannot dispense any medication without these completed forms.  

***Note:  A “Medication Authorization,” which is included in the packets for each health condition, needs to be completed for each medication.  Here’s a quick link, if your child has more than one medication.

Life-Threatening Food and/or Insect Allergy (Forms for this Section Available Here)

  • Allergy IHCP

  • Medication Authorization (one for each medication)

  • Nut & Seed Restricted Lunch Table Guidelines

  • Lunch Table Needs Lunchroom Addendum

  • Parent Medication Drop-Off Checklist

  • Letter from Principal—Randolph Student Medications at School

Asthma (Forms for this Section Available Here)

  • Medication Authorization (one for each medication)

  • Parent Medication Drop-Off Checklist

  • Letter from Principal—Randolph Student Medications at School

Diabetes (Forms for this Section Available Here)

  • Diabetes IHCP

  • Medication Authorization (one for each medication)

  • Parent Medication Drop-Off Checklist

  • Letter from Principal—Randolph Student Medications at School

Seizure Disorder (Forms for this Section Available Here)

  • Seizure IHCP