School Diabetes Care Authorization Form

Student Information

Student Name

Date of Birth

School Name

Grade

Teacher

Parent/Guardian Information

Parent/Guardian Name

Phone

Physician Information

Physician Name Physician Phone

Diabetes Care Details

Type of Diabetes Medications/Insulin (List) Blood Glucose Monitoring Instructions Treatment of Low/High Blood Glucose Dietary Considerations/Meal Plan Physical Activity Guidelines Additional Information / Special Instructions

Authorization

I authorize the school staff to provide care as indicated above and to communicate with my child's healthcare provider as needed.

Parent/Guardian Signature Date

Physician Signature Date