Medical Needs
☐ Blood glucose monitoring as needed
☐ Insulin administration (specify method): _________________
☐ Access to diabetes supplies at all times
☐ Emergency glucagon administration training for staff
☐ School nurse availability during school hours
Academic Accommodations
☐ Unlimited bathroom and water access
☐ Flexible testing times if blood sugar is high/low
☐ Make-up work for medical appointments
☐ Alternative activities during high-risk times (PE, etc.)
☐ Blood sugar checks during standardized tests
Emergency Procedures
☐ Emergency contact information readily available
☐ Glucagon emergency kit location: _________________
☐ Staff trained in diabetes emergency response
☐ 911 called for severe low blood sugar
☐ Parent notification procedures: _________________
Additional Notes
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Signatures
Parent/Guardian: _________________ Date: _________________
School Representative: _________________ Date: _________________
Student (if applicable): _________________ Date: _________________