SETTLEMENT AGREEMENT BETWEEN
THE UNITED STATES OF AMERICA
AND
ALEXANDRIA COUNTRY DAY SCHOOL,
ALEXANDRIA, LOUISIANIA
DJ#: 202-33-43

I. BACKGROUND AND PARTIES

The parties to this Settlement Agreement ("Agreement") are the United States of America and Alexandria Country Day School ("Alexandria School"), located in Alexandria, Louisiana.
This matter was initiated by a complaint filed with the United States Department of Justice (the "United States") against Alexandria School, D.J. No. 202-33-42, alleging violations of title III of the Americans with Disabilities Act of 1990 ("ADA"), 42 U.S.C. §§12181-12189, and its implementing regulation, 28 C.F.R. Part 36.
In the complaint, [redacted], parents of a then six-year-old girl with Type I diabetes, alleged that Alexandria School denied their daughter admission to Alexandria School on the basis of diabetes. Allegedly, Alexandria School denied the [redacted] request that the school enroll their daughter and supervise her in testing her blood glucose level and administering insulin using her insulin pump, in addition to other daily diabetes care practices.
The United States is authorized to investigate alleged violations of title III of the ADA, and to bring a civil action in federal court if the United States is unable to secure voluntary compliance in any case that involves a pattern or practice of discrimination or that raises issues of general public importance. 42 U.S.C. § 12188(b).
Alexandria School is a place of public accommodation covered by title III of the ADA. 42 U.S.C. § 12181(7)(J); 28 C.F.R. § 36.104.
The ADA prohibits public accommodations from discriminating against an individual on the basis of disability in the full and equal enjoyment of its goods and services. 42 U.S.C. § 12182(a). Ensuring that private schools do not discriminate against persons with diabetes is an issue of general public importance.
Alexandria School denies the allegations of the complaint. Nevertheless, to ensure full compliance with the ADA, Alexandria School agrees to establish and implement policies and procedures, set forth below, that are designed to afford children with diabetes a benefit equal to that provided to others, and to make reasonable modifications in policies, practices, and procedures when necessary to provide appropriate supervision or assistance to children with diabetes in order to ensure safe participation in all school activities.
In consideration of the terms of this Agreement, and in particular the provisions in Sections II-III, the Attorney General of the United States agrees to refrain from undertaking further action in this case, except as provided in Section III(D).
The parties agree to resolve this matter as set forth below.

II. TERMS OF AGREEMENT

Alexandria School agrees not to discriminate against any child on the basis of diabetes; that is, Alexandria School agrees to provide all children with diabetes with an equal opportunity to attend Alexandria School and to participate in all programs, services, or activities provided by Alexandria School. Alexandria School will not refuse to admit any child to any of its sessions or programs because the child has diabetes or requires diabetes care unless the child's participation would result in a "fundamental alteration" of the program, service or activity as set forth in 28 C.F.R. § 36.302.
Alexandria School agrees to evaluate children, on a case by case basis, and make reasonable modifications for children with diabetes pursuant to Federal and Louisiana law. Modifications may include, but are not limited to, supervising and monitoring children with diabetes while using blood glucose monitoring tests, insulin pumps, syringes, or other diabetes related medical equipment; or permitting such children to eat while participating in any program, service, or activity, whether on Alexandria School's premises or elsewhere while participating in Alexandria School's educational or extracurricular programs.
Alexandria School will take necessary steps to ensure that a child's diabetes care is integrated into the usual daily routine and program at Alexandria School to the greatest extent possible in accordance with the ADA and applicable state and local law.
Alexandria School will adopt a diabetes management policy ("Policy"), which is attached hereto as Appendix A and is incorporated herein by reference. Alexandria School will print and maintain copies of the Policy in a central location, provide the Policy to any interested party requesting it, and will incorporate the Policy into its standard operating policies in accordance with applicable state and local law.
Alexandria School will provide training to its staff regarding the terms and conditions of the Policy and to facilitate the implementation of the Policy.
When informed that a child who has applied to Alexandria School or its programs has diabetes:
1. Alexandria School will advise the child's parents, guardians, or caretakers of the Policy, and advise that Alexandria School will comply with all applicable federal, state, and local laws;
2. Unless circumstances reasonably permit an accelerated review of the application consistent with the Policy, no less than two weeks prior to the first day of any session, program or activity, Alexandria School may require that the child's parents provide Alexandria School with any or all of the following:
  1. A completed Diabetes Management Plan, such as attached at Appendix B, clearly detailing any and all necessary care for the child's diabetes management and signed by the child's primary care physician or endocrinologist;
  2. A completed Physical Examination Form, such as attached at Appendix C, and any other clear, typewritten health-related documents deemed relevant by the child's primary care physician or endocrinologist;
  3. Information regarding all equipment, food, and substances to be provided by the child's parents/guardians that are not regularly provided by Alexandria School and that are necessary to meet or comply with the child's Diabetes Management Plan, the Physical Examination Form, the Policy, and any health-related documents as noted in the preceding subparagraph (ii);
  4. Written permission to undertake steps indicated and requested on the child's Diabetes Management Plan, and permission to respond to any diabetes-related or other emergency in a manner consistent with those instructions or emergency protocols;
  5. Information and instructions regarding containers for proper disposal and operation of all materials including, but not limited to, operation of the child's blood glucose meter and insulin pump; and
  6. That the parents, guardians or their designees be available to attend meetings on the first day of a session or program and be available in compliance with the Policy.
3. Alexandria School will communicate with parents or guardians as set forth in the Policy and Diabetes Management Plan about the child's diabetes management, diabetes care, or diabetes health-related concerns;
4. Alexandria School will ensure compliance with the Diabetes Management Plan and Policy, and permit the child to self-manage his or her diabetes consistent with the child's ability, skill, maturity, and development level; and
5. Alexandria School will respect the child's and his or her family members' rights to confidentiality and privacy consistent with all pertinent local, state, or federal laws, regulations, or requirements.
Alexandria School will arrange to provide basic training to personnel who may be responsible for children with diabetes at Alexandria School. The basic training will include a general overview of diabetes and typical health care needs of individuals with diabetes; recognition of common symptoms of hypoglycemia and hyperglycemia; and ways to get help quickly. The parents or guardians of any child with diabetes are responsible for providing, at their cost, all appropriate testing equipment, diabetes supplies, and special food necessary for the needs of their particular child. Alexandria School, at the request of the parents or guardians and with their input, will arrange training for appropriate personnel regarding the needs of a particular child with diabetes. This child-specific training may be given by a parent or guardian, or by a qualified person agreed upon by the parents or guardians. The parents or guardians of a particular child with diabetes should be available to provide assistance to, and respond to inquiries from, Alexandria School personnel about any matter or concern related to the care or treatment for that particular child with diabetes. Alexandria School personnel should be authorized to seek clarifying information from the child's health care team regarding questions about the medical orders.
Alexandria School will maintain records at its office of all admission inquiries on behalf of children with diabetes, including insulin-dependent diabetes, and the disposition of such inquiries, for a period of three (3) years from the date of the inquiry.
Alexandria School will not retaliate against or coerce in any way any person who is trying to exercise his or her rights under this Agreement or the ADA.

III. ENFORCEMENT AND IMPLEMENTATION

Compliance Reports. Alexandria School will provide written reports to the United States regarding compliance with this Agreement. The first, second, third, and fourth reports shall be due six (6), twelve (12), eighteen (18) and thirty (30) months, respectively, from the entry of the Agreement. Each of the reports must state the number of applicants with diabetes who applied to attend any program, the particular diabetes care requested for such applicant, the procedure followed to determine whether to admit such applicant to the program, any reason admission to the program was denied, and if an applicant was admitted, what diabetes care was agreed upon. Alexandria School will maintain records to document all statements in the report. Alexandria School shall also submit detailed information about any complaints to Alexandria School by children with diabetes or their parents or guardians, or actions taken by Alexandria School that involve any child who has diabetes, including any decision to deny a child's request for an accommodation after admission to Alexandria School or any request or other action by Alexandria School that contributes to a child's removal or departure before the end of a session for which the child was enrolled. The parties agree to adhere to all requirements for confidentiality.
Complaints. During the term of this Agreement, Alexandria School will notify the United States if any individual brings any lawsuit, complaint, charge, or grievance alleging that Alexandria School discriminated against them on the basis of disability. Such notification must be provided in writing via certified mail within fifteen (15) days of when Alexandria School has received notice of the allegation and will include at a minimum, the nature of the allegation, the name of the individual bringing the allegation, and any documentation possessed by Alexandria School relevant to the allegation.
Notices. All notices, reports, or other such documents required by this Agreement shall be sent to the Parties by fax and by delivery via Federal Express to the following addresses or to such other person as the parties may designate in writing in the future:
For notices to the United States:
Allison Nichol, Chief
Attention: Robert Mather
Disability Rights Section
Civil Rights Division
U.S. Department of Justice
1425 New York Avenue, NW
Washington, D.C. 20005
(202) 307-2236 (telephone)
(202) 616-6862 (facsimile)

For notices to Alexandria School:
Doug Godard, President
Alexandria Country Day School
5603 Bayou Rapides Road
Alexandria, LA 71303
(318) 448-1475 (telephone)
(318) 442-7924 (facsimile)
Enforcement of Agreement. The United States may review compliance with this Agreement at any time and may enforce this Agreement if the United States believes that any requirement therein has been violated. If the United States believes that this Agreement or any portion of it has been violated, it will specifically notify Alexandria School's President in writing and will attempt to resolve the issue or issues in good faith. The United States will give Alexandria School thirty (30) days from the date it notifies Alexandria School of any breach of this Agreement to cure that breach, prior to instituting any court action. If the United States is unable to reach a satisfactory resolution of the issue or issues raised within thirty (30) days of the date it provides notice to Alexandria School, it may institute a civil action in federal district court to enforce the terms of this Agreement or title III and may, in such action, seek any relief available under the law.
Term of the Agreement. The Agreement shall become effective as of the date of the last signature below and shall remain in effect for three (3) years from that date.
Entire Agreement. This Agreement, and all appendices attached, constitute the entire agreement between the parties on the matters raised herein, and no other statement, promise, or agreement, either written or oral, made by any of the parties or agents of any of the parties, that is not contained in this written Agreement or attachments, shall be enforceable regarding the matters raised herein.
Copies Available. A copy of this Agreement may be made available by the United States or Alexandria School to any person upon request.
Settlement of Claims. This Agreement fully and finally resolves any and all of the allegations of the complainants and the United States in this case. It does not purport to remedy other potential violations of the ADA by Alexandria School.
Binding Effect. This Agreement shall be binding on Alexandria School, its agents and employees. In the event Alexandria School seeks to transfer or assign all or part of its interest in any facility covered by this Agreement, and the successor or assign intends on carrying on the same or similar use of the facility, as a condition of sale Alexandria School shall obtain the written accession of the successor or assign to any obligations remaining under this Agreement for the remaining term of this Agreement.
Non-waiver. Failure by the United States to seek enforcement of this Agreement pursuant to its terms with respect to any instance or provision will not be construed as a waiver to such enforcement with regard to other instances or provisions.
Signatory. A signatory to this document in a representative capacity for Alexandria School represents that he or she is authorized to bind that party to this Agreement.

For Alexandria County Day School	For the United States of America:
___________________________ Doug Godard, President Alexandria Country Day School 5603 Bayou Rapides Road Alexandria, Louisiana 71303	___________________________ Thomas E. Perez Assistant Attorney General Civil Rights Division
Dated: _____________________	SAMUEL BAGENSTOS Principal Deputy Assistant Attorney General Civil Rights Division ALLISON NICHOL, Chief KATHLEEN WOLFE, Acting Special Legal Counsel RENEE M. WOHLENHAUS, Deputy Chief Disability Rights Section Civil Rights Division

Attachments	__________________ ROBERT J. MATHER Trial Attorney Disability Rights Section Civil Rights Division U.S. Department of Justice Washington, DC 20530 Telephone: (202) 307-2236 Fax: (202) 616-6862 robert.mather@usdoj.gov Dated: _______________________

APPENDIX A

Alexandria Country Day School Policy on Diabetes Management

Alexandria Country Day School ("Alexandria School") is committed to complying fully with the Americans with Disabilities Act ("ADA") and any other applicable laws and regulations pertaining to children with disabilities.

Children with diabetes Type I or Type II who attend Alexandria School may require assistance with diabetes management. The management regime of every child with diabetes may be different and, for this reason, it is the view of Alexandria School that one Policy cannot dictate the particular protocol followed by Alexandria School for all individuals. Alexandria School will make an individual assessment of the special needs of each child with diabetes on a case-by-case basis and will work with families to provide reasonable modifications to children with diabetes in accordance with applicable laws. Successful participation and accommodation of the children depend on an actively cooperative relationship and ongoing communication between the parents or guardians of the children and Alexandria School.

Where circumstances reasonably permit an accelerated review of the application, parents or guardians who wish to enroll a prospective child with diabetes should submit a complete application for the child at least one month ahead of the scheduled start date for school session or program, to permit adequate time for the staff to meet with the parents or guardians of the child to examine the individual needs of the child on a case-by-case basis and to take appropriate steps to comply with pertinent laws.

Within one week of the child's admission to a particular session or program, Alexandria School will send to the parents or guardians a copy of this Policy, a Diabetes Management Plan Form, and a Physical Examination Form. A reasonable time (i.e., ten (10) business days) prior to the beginning of the session or program, the parents or guardians of a child with diabetes will send the Director at Alexandria School a completed Diabetes Management Plan Form, typewritten in easy to understand terms, detailing care necessary for the child's safety; a completed Physical Examination Form; and a signed general release, if the same release is required of all other children regardless of disability.

For current children who require treatment for diabetes for the first time during any session or program, parents or guardians of these children should immediately notify Alexandria School, submit the completed Diabetes Management Plan Form as set forth above, and comply with the remaining aspects of this Policy in a timely manner to allow Alexandria School to make good faith efforts for continuation of the session or program consistent with this Policy.

Because each child's care is different and the activity levels of each child may be different, this Policy should not be construed to prevent Alexandria School from working with health care professionals and the child's guardians or parents in an effort to expedite the child's admission or improve the child's experience.

Parents or guardians will be available at Alexandria School=s request to attend and participate on the first day of a session or program with the child and, if deemed necessary by either party, to attend a prior run-through of the first day, and to continue to meet with and advise the staff working with the child about proper diabetes care. Parents will be available by phone or have other emergency contacts (which may include the child's health care provider) available by phone each day that the child is participating in a session to answer questions from Alexandria School or the child regarding the child's management of diabetes care and to approve particular actions related to proper care when necessary.

Parents or guardians will provide specific information and training about the child's diabetes and particular needs related to diabetes care to Alexandria School, and will permit the child's personal health care providers to share information with Alexandria School staff and other health care personnel when necessary to assure the child's safety and compliance with the child's Diabetes Management Plan. The information and training should cover all equipment, food, and substances to be provided by the parents/guardians that are not regularly provided by Alexandria School; and procedures for proper use and maintenance of all equipment and materials, including, but not limited to, keeping the child's blood glucose meter and insulin pump in good working order.

Parents or guardians will promptly inform Alexandria School of relevant changes in the child's health status. The parents or guardians will provide, along with instructions about proper maintenance or use of all items, all supplies and equipment necessary for the child's safe participation in all activities.

Parents or guardians will provide and properly maintain all supplies and equipment for the child's diabetes and assist with proper disposal of equipment and supplies. Parents or guardians will provide written permission to undertake the steps indicated on the child's Diabetes Management Plan and Physical Examination Form, and, where circumstances reasonably permit, will provide all applicable releases (if such releases are required of all children, regardless of disability) in writing two weeks before a child joins any session or program at Alexandria School.

Training of Personnel

In accordance with applicable law, including those regulations enforced by the applicable Department of Public Health, if a child with diabetes applies for any session or program, Alexandria School will arrange for a qualified health care professional to provide basic training to the appropriate personnel at Alexandria School. That basic training will include a general overview of diabetes and typical health care needs of individuals with disabilities, recognition of common symptoms of hypoglycemia and hyperglycemia, and ways to get help quickly. The person assigned to do the training will also provide assistance and respond to inquiries from parents or staff about any matter or concern related to the care or treatment for a child with diabetes.

Primary teachers and any other teacher or staff member who has primary responsibility for a child with diabetes for more than 60 minutes in any one day will have received training that enables Alexandria School to provide all care required to comply with applicable law. Such training includes (but may not be limited to) an overview of diabetes, general information on how to recognize signs and symptoms of hypoglycemia and hyperglycemia, and diabetic care practices related to glucose monitoring and regulating glucagon and insulin administration, including by insulin pump. In addition, depending on the unique needs of the child, training may include information about dietary requirements for individuals with diabetes in general and particular information about dietary requirements for particular children, and training and guidance from parents or guardians of children about any reasonable modifications needed by a child as identified in each child's Diabetes Management Plan (which, where circumstances reasonably permit, is to be provided by the parent or guardian to Alexandria School at least ten (10) business days prior to any session or program) and related documents. Parents or guardians must provide information and training necessary for staff to be trained with regard to any unique needs of their child.

Monitoring Blood Sugar Levels

Parents or guardians will check the child's blood sugar levels each morning before the child arrives at Alexandria School to ensure they are within the established Atarget range@ in the child's Diabetes Management Plan. Parents or guardians agree to be available to be contacted as deemed necessary to provide information, assistance, or guidance so that Alexandria School satisfies each child's Diabetes Management Plan. If the child self-identifies, or staff recognizes symptoms of hyperglycemia or hypoglycemia, the staff will assist the child to check blood sugar and treat the symptoms. Alexandria School will assess the level of assistance or supervision that is reasonable depending on the individual needs of the child in the particular situation and provide whatever assistance is appropriate in the situation consistent with the Plan and applicable law.

Further, parents or guardians will furnish all appropriate meals and snacks that are not regularly provided by Alexandria School and that are necessary to meet the child's needs. The parents or guardians will also ensure that the carbohydrate content falls within the proper amounts set forth in the Diabetes Management Plan so that the totals will be predetermined and calculated by the parents. Carbohydrate values will be calculated and provided on labels on each food item provided by the parents so that the staff may monitor the appropriate use of insulin and insulin pumps or other equipment to administer insulin.

At the onset of any symptom of hyperglycemia or hypoglycemia, the child will notify the staff that the child needs to have a glucose test. Should the staff or nurse notice any symptom(s) of hyperglycemia or hypoglycemia, the staff or nurse will take steps reasonably consistent with the Diabetes Management Plan.

Insulin and Insulin Pumps

Children with diabetes are responsible for arriving at Alexandria School with all necessary supplies. Children may carry their own medical supplies and snacks in a safe fashion that meets local code or safety standards for the care and disposal of medical supplies so that these supplies are in close proximity to the child. To that end, children with insulin pumps are expected to come to Alexandria School with a fully functional pump, back-up insulin and syringes, and glucose tablets for low sugar episodes, and any other equipment necessary for that child. When the child cannot hold these supplies, the supplies will be held at the administrative office, health office, or by a staff member.

Nothing in this process shall prevent Alexandria School from exercising its discretion for the benefit of the child. This policy is not intended to provide fixed rules for dealing with all care involving diabetes; however, the policy sets a minimum standard for ADA compliance. This policy is not intended to serve as a contract with any individual child. The policy may be modified or updated at any time following prior approval by the Department of Justice during the pendency of the Agreement in the case identified below¹. Should you have any questions, the President will be happy to answer your questions or help you get the information you need.

¹Settlement Agreement Between the United States of America and Alexandria Country Day School, Alexandria, La., D.J. No. 202-33-43, June 1, 2011.

APPENDIX B

PHYSICAL EXAMINATION FORM

To be completed and approved by the child's diabetes nurse educator, endocrinologist, or primary care provider/physician. Please attach additional pages as needed.

Dear Diabetes Team:

Your cooperation in supplying the following information about an applicant for Alexandria Country Day School is greatly appreciated. The child will not be accepted without your approval on this form.

To Parent/Guardian: Please complete boxed information BEFORE submitting to Physician.

Name of applicant___________________________ Gender (circle one) M F

Date of Birth _______/_________ Address:____________________________________

Date of most recent exam: _____________________

I have read the Diabetes Management Plan, attached to this form, and certify that it provides an easy to understand, complete regime of care for this child's safety at Alexandria Country Day School, I recognize that the child will be active at this facility and represent that this plan accounts for applicable varying activity levels.

Have any complications of health or disabilities been detected? Yes/No (circle one)

If yes, please specify: ________________________________________________________________________

Is the child emotionally and physically mature or responsible enough to independently manage his/her health concerns? Yes ______; No _____.

Do you have any specific concerns regarding the management of this child's health or health at school not fully described in the Diabetes Management Plan? Yes____, No____.

If yes, please explain:______________________________________________________

Do you recommend any limitation on child's activity while at the day care facility beyond those described in the Diabetes Management Plan? Yes _______ No ______ If yes, please describe:_______________________________________________________ _______________________________________________________________________

Do you have any other information that is relevant to the care of this child? Yes __ No __ If yes, please describe: _____________________________________________________

________________________________________________________________________

I certify that the information above is correct to the best of my knowledge and agree to answer questions and provide management guidance to Alexandria Country Day School as requested by the facility at the sole cost and expense of the parent/legal guardian of the child.

Primary Care Physician/Endocrinologist's Name (typed or printed)

_____________________________________________________________

Address: _____________________________________________________

Phone: (____)__________

Primary Care Physician/Endocrinologist's Signature:

_________________________________________________

Parents/Guardians name (typed or printed)

_________________________________________________

Address: _______________________________________________________________

Phone: (____)_________________

Parents/Guardian Signature:

Father: ____________________________

Mother: ____________________________

Legal Guardian: ____________________________

APPENDIX C

DIABETES MANAGEMENT PLAN

Dated: ____________________

This plan must be completed by the child's personal health provider/physician and parents/guardian and immediately updated by these persons with any new information in the future. All entries must be completed or the plan will be deemed incomplete and unsatisfactory. (Please attach additional pages as needed)

(This section to be completed by parents/guardian of child)

Effective Dates: ______________________________________________________
Child's Name: _______________________________________________________
Date of Birth: _______________________________________________________
Physical Condition (Identify and Explain): ________________________________
___________________________________________________________________
___________________________________________________________________
Date of Diagnosis: ____________________________________________________
Grade: _____________________________________________________________
Contact Information: Circle the primary contact person and phone number
Mother/Guardian: ____________________________________________________
Home Address: _____________________________________________________
Employer: _________________________________________________________
Employer's Address: ________________________________________________
Telephone: Home: ___________ Work: ___________ Cell: _____________
Father/Guardian: _____________________________________________________
Home Address: _____________________________________________________
Employer: _________________________________________________________
Employer's Address: ________________________________________________
Telephone: Home: ____________ Work: _____________ Cell: ______________
Who has custody of the child? __________________________________________
(This section to be completed by child's doctor/health care provider)
Child's Doctor/Health Care Provider:
Name: ____________________________________________________________
Address: __________________________________________________________
Telephone: _____________________________________________________
Emergency Number: ________________________________________________
Other Emergency Contacts:
Names: ___________________________________________________________
Relationship: ______________________________________________________
Telephone: Home: ____________ Work: _______________ Cell: ____________
Notify parents/guardian or emergency contact in the following situations: ________
___________________________________________________________________
___________________________________________________________________
Recommended monitoring of child: ______________________________________
___________________________________________________________________
___________________________________________________________________
Specify any medical time requirements: ___________________________________
___________________________________________________________________
Can child perform own monitoring? ____Yes ____No
Exceptions: ________________________________________________________
__________________________________________________________________
Identify the type of any meter, monitor, nebulizer, applicator, needle, pump, or any other devices necessary for the child's Diabetes Management Plan (include model and instruction booklet): _______________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Is the type of blood glucose meter, monitor, nebulizer, or test, necessary for the child's Diabetes Management Plan approved by the Federal Food and Drug Administration for over-the-counter sale without a prescription?
___Yes ___No ___Do Not Know
What signs does the child demonstrate when child is symptomatic? _____________
___________________________________________________________________
Foods to avoid, if any: ________________________________________________
Instructions for when food is provided to the child (e.g., as part of a party or food sampling event): _____________________________________________________
___________________________________________________________________
List, identify, and explain any restrictions to exercise, sports, or any other activities:
___________________________________________________________________
___________________________________________________________________
Treatment Supplies to be kept at the child care facility and provided by parent/guardian are as follows (please provide specific instructions regarding the storage and treatment of all supplies):_____________________________________
___________________________________________________________________
___________________________________________________________________
Provide instructions on the use and handling of monitoring equipment, including lancets, test strips, cotton balls, or other items used while conducting blood glucose tests (must be in accordance with manufacturer's instructions, if applicable):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Provide instructions on how to determine if test results, are within the normal or therapeutic range for the child, and any restrictions on activities or diet: _________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Provide instructions on how to identify symptoms of hypoglycemia or hyperglycemia: ______________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Provide instructions on what actions to take when results are not within the normal or therapeutic range for the child and any restrictions on activities or diet: ________
___________________________________________________________________
___________________________________________________________________
Any specific instructions provided by child's physician/health care provider relevant to the child's diabetes care: ______________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

For children with additional medical concerns, please complete supplemental form.

This Diabetes Management Plan has been completed and approved by:

____________________________ __________________________
Child's Physician/Health Care Provider Date
(Signature)

I attest that the aforementioned information is true and accurate. I give permission to the Alexandria Country Day School to perform and carry out care tasks as outlined in the Diabetes Management Plan. I also consent to the release of the information contained in this Diabetes Management Plan to all staff members and other adults who have custodial care of my child such as those persons on the emergency list and who may need to know this information to maintain my child's health and safety. A written revocation or amendment to this document must be delivered to the aforementioned child care facility by the child's Parent/Guardian in order to effectuate a revocation of the same. The aforementioned child care facility reserves the right to request additional documentation after review of the within document based on its reasonable discretion, and/or the requirements of State law and the regulations and policies.

Acknowledged, approved and received by:

_______________________________ _________________________
Child's Parent/Guardian (Signature) Date

_______________________________
Telephone Number

_____________________________ _________________________
Child's Parent/Guardian (Signature) Date