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Required Form(s) for Students with Life-Threatening Allergy and/or Asthma


Dear Parents/Guardians:


If your child has a food or insect allergy or asthma that may warrant the use of a rescue medication during school on a regular or as needed basis, please read this notice carefully. New Jersey State Law requires that physicians complete and sign an Allergy Action Plan and/or Asthma Treatment Plan before the start of each school year for their patients with life threatening allergies or asthma who may require use of an inhaler or Epinephrine during the day while at school.


Montgomery Township School District Policy R5330 requires that all students who require an auto-injector of epinephrine or an inhaler, including those who self-administer, must submit an MTSD Allergy Action Plan and/or Asthma Treatment Plan to the school nurse at the beginning of each school year.

In order to maintain a safe and healthy environment for your child next year, all paperwork (and any medications you wish to store in the health office during the school year) must be submitted to the health office in the school your child attends before the first day of school in September. Please print the pertinent required document(s) and take them with you to your child’ doctor’s appointment for completion; a parent/guardian signature is also necessary on each form.

Please note that your child will not be allowed to participate in athletics, field trips, overnight trips or school sponsored events without a completed and current MTSD Allergy Action Plan or seizure action plan on file in the health office. It’s important to remember that most physicians have a 2-3 month wait time when scheduling appointments. Please schedule your child’s appointment today for July or August.

If you have any questions or concerns regarding your child’s health care needs for the upcoming school year, please contact the nurse in the building that your child attends.


We wish you a safe, happy and healthy summer.


The MTSD Nursing Staff


If your child has Epinephrine prescribed, please complete the "Allergy Action Plan" form.
If your child has an inhaler prescribed, please complete the "Asthma Treatment Plan" form.