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 ______________________ 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 Knoxville 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)
Approved: 7/15/2019 Reviewed: Revised:
