Legal Rights of Children with Epilepsy in School & Child Care

The following form is to be completed by the physician who is actively treating the child for the seizure disorder.
Limitations of the child:
Emergency Medical Services should be called when:
Medications to be given at Day Care
Name of Medication Dose/Route Time Possible Side Effects
Emergency Medication – If child receives diazepam rectal gel or another emergency medication, please list the
appropriate procedures to follow prior to, during and after administration.
Physician’s Directives to EMTs: Transportation to the hospital should be provided under the following conditions.
Staff will not prevent EMTs from transporting a child that they believe requires emergency hospital care.
Physician Name (printed)
Physician’s Signature
Date Signed
Physician’s Phone #
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By signing below I am agreeing that the center staff will follow the steps laid out in the Seizure Disorder Emergency
Treatment Plan to ensure the child’s safety prior to the arrival of the EMT’s. The staff will also provide this information
sheet, including the physician’s directives and the seizure observation record to the EMT’s.
Date Signed
Center Management
Seizure Disorder Emergency Treatment Plan
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