- J
- Students
File: JLCM-E-2 (pdf)
Adopted: June 13, 2023
PLAN FOR MEDICALLY NECESSARY TREATMENT AT SCHOOL
Student Name: _____________________________________________________________________________________________
Student ID # and Date of Birth: _________________________________________________________________________________
Parent/Guardian Name(s) & telephone number: ____________________________________________________________________
__________________________________________________________________________________________________________
Name and Contact Information for private health care specialist who will provide proposed medically necessary treatment on school district property
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Treatment to be provided on District property:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Location:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Schedule:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
School Administrator Signature Date
__________________________________________________________________________________________________________
Parent/Guardian Name Signature Date
__________________________________________________________________________________________________________
Private Health Care Specialist Signature Date