This form is for a student being treated by a healthcare provider for a seizure disorder.

Medication is permitted in accordance with district policy FFAC(LEGAL). A student can carry emergency asthma or anaphylaxis medication for self-administration if the medication has been prescribed for that student; the student has demonstrated to the prescribing physician and the school nurse the skill level necessary to self-administer the prescription medication; the self-administration is done in compliance with the prescription, or written instructions, from the prescriber; and written permission from the child's physician and parent are on file in the nurse's office which indicates that the student is capable of self-administering the medicine. All other requirements under policy must also be met.