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Health Office Forms

Health Office Forms
Click the links below to download the
following Health Office forms
      FORM                                                             DIRECTIONS
Allergy Action Plan All students who have an epinephrine injection device ordered for a severe allergic reaction must have this Allergy Action Plan completed and signed by their physician. The parent/guardian must complete the back of the form and sign it. The form is then submitted to the nurse along with the medication that has been ordered.
Medication Request This form must be completed by the child's doctor and signed by a parent/guardian before medication can be administered during the school day.
Asthma Treatment Plan All students using asthma medication while at school must have this asthma treatment plan completed and signed by their physician. A parent/guardian must also sign the form, & return to the school nurse with the medication.
Student Physical Exam This form must be completed by a student's healthcare provider and submitted as part of registration (the exam must have been done within one year before entrance to school) and for documenting annual exams.
Annual Health History
This form must be completed annually by the student's parent/guardian and returned to the school.

    Grade 6  Immunization         Form

Documentation of immunization for children entering sixth grade must be recieved before the commencement of school in September. Please have your child's primary care provider complete this form and forward to the school nurse.