Please download and return completed forms to the school nurse.
Allergy - Food
This form is to be used for students who have a severe allergic reaction to a food or foods. It requires physician orders for medication to be used in an emergency in the school setting and the physician's signature.
Allergy - Non-Food
This form is to be used for students who have a severe allergic reaction to bee stings, latex or other environmental triggers. It requires physician orders for medication to be used in an emergency in the school setting and the physician's signature.
This form is to be used for students who require a nursing plan to help them deal with asthma symptoms during the school day. It requires a physician to write directions for this asthma care.
Athletics & Activities
This form should be completed for students for the following school years:
• Grade 1
• Grade 3
• Grade 7
These forms are for physicians and parents of students with diabetes. They provide the school nurse with appropriate information to care for the student and their diabetes during the school day. These forms are from the American Diabetes Association.
This form is to be used for students who have a health problem, which is not allergy or asthma related, and need an emergency plan implemented for their safety in the school environment. If medications are an integral part of this plan please attach the Medication Consent Form as well.
Lead Testing Form for Students
This form should be completed when requesting medication be dispensed to your child during the school day. School procedure regarding medications is included with the permission form.
This form should be completed by your child's Primary Health Care Provider for the following school years:
• Entry to school (Kindergarten or Grade 1)
• Grade 6
• Grade 11
This exam may be done within one year from the start of the school year the physical is required in. Example: If school starts in August 2022, the exam date can be as early as August 2021.
School Immunization Requirements
- 4 doses of tetanus, diphtheria, and acellular pertussis (1 dose on or after the 4th birthday) Usually given as DTP or DTaP or DT or Td
- 4 doses of polio (4th dose on or after 4th birthday and at least 6 months after previous dose given) A 4th dose not necessary if the 3rd dose was administered at age 4 years or older and at least 6 months after the previous dose
- 2 doses of measles, mumps, rubella (Usually given as MMR)
- 3 doses of hepatitis B
- 2 doses of varicella (chickenpox) or evidence of immunity in the form of a written statement from physician/designee indicating a month and a year of disease or serologic proof of immunity.
- 1 dose of tetanus, diphtheria, acellular pertussis (Tdap) on the first day of 7th grade
- 1 dose of meningococcal conjugate vaccine (MCV) on the first day of 7th grade
- 1 dose of meningococcal conjugate vaccine (MCV) on the first day of 12th grade
- Religious belief
- Philosophical/strong moral or ethical conviction
- Tdap (1) 7th grade
- DTaP (4) kindergarten
- Polio (4) kindergarten
- HepB (3) kindergarten
- MMR (2) kindergarten
- Varicella (2) kindergarten
- MCV (2) 7th -12th grades
If additional doses are required and are medically appropriate within the first five days of school, the child shall have either the final dose during that five-day period or the child shall have the next scheduled dose and shall also provide a medical certificate setting out the schedule for the remaining doses.