Health Office Forms

Individualized Health Plan-IHP

• In the event that your child does suffer from life threatening allergies that requires an Epinephrine auto injector as a treatment, an IHP or individual health plan will be created for your child.
• An IHP is an individual health plan that is initiated and developed by you and the school nurse when a child’s health care needs are more complex. This plan contains an emergency plan for the management and treatment of an allergic reaction should one occur while the child is at school.
• Your child’s IHP will be shared with their teachers, cafeteria, transportation and administration with team effort and collaboration to ensure your child’s safety at school.
• Your child’s IHP will be updated each school year and as necessary.

In order for an IHP to be created for your child it is the parent's responsibility to provide the following forms to the school nurse:

• Allergy Health History Form
• Seizure Questionnaire Form
• Medication Authorization Form
  • Medication authorization form for each prescribed medication.
  • The delivery of all medications ordered for your child brought to the school by an adult.
  • Please return or e-mail completed forms to the school nurse

Form instructions for printing

 

The NYS Department of Health recommends students have an annual dental exam

• Please have your dentist complete the Dental Health Certificate.
• Please return or e-mail completed form to the school nurse.

Form instructions for printing

Grade Level Mandatory Immunization

• Grade Level Mandatory Immunization.
• The immunization record is obtained from your health care provider and must be signed and stamped by a healthcare provider.
• If necessary, please have your NYS healthcare provider translate your child’s record.
• Please return or e-mail completed forms to the school nurse.

Immunization Records

• The certificate of immunization shall be prepared and signed by a healthcare provider licensed in New York State and must specify the vaccines administered and the exact dates of administration. A record issued by NYSIIS, the CIR, an official immunization registry from another state, an electronic health record, and /or an official record from another country may be accepted as a certificate of immunization.
• Must be received within 14 days of the first day of school, or your child will be excluded from attending school.
• For students entering the district from another country, this record must be received within 30 days of the first day of school, or your child will be excluded from attending school.
• If your child does not meet all of the New York State mandated vaccination requirements for school entry, they will need to follow the New York State ACIP Recommended Catch Up Schedule and receive any missing vaccines within 14 days of the minimal interval. Documentation of any vaccines received must be brought to the school nurse.
• Download the New York State Mandated Immunizations for School Entry and the New York State Recommended Catch Up Schedule.
• If you have any questions regarding your child’s immunization status, please do not hesitate to contact your child’s nurse prior to any upcoming appointment with their pediatrician.

Immunization Medical Exemption

• If a student has a medical exemption to a vaccination, a physician licensed to practice medicine in New York State must complete, sign, and stamp this form. This form must be reissued annually.

Immunization Medical Exemption Form

 Form Instructions for Printing

NYS Physical Examination

• This form must be completed in full by a NYS licensed Medical Doctor, Physicians Assistant or Nurse Practitioner.
• The completed form must be signed and stamped by the Health Care Provider.
• Please return or e-mail completed form to the school nurse immediately after your child receives his/her physical exam.

Mandated NYS Physical Examination Form

Form Instructions for Printing

Form on Separate Pages - page 1, page 2

Medical Accommodation

• This form is to be completed by your child’s healthcare provider to request any specific accommodations that are needed at school due to a medical condition.( for example: need for wheelchair, prolonged gym/recess exemptions, transportation accommodations).
• Once this form is completed and submitted to your school nurse it will be sent to the district’s school physician for review and needed approval.
• Please return or e-mail completed form to the school nurse.

Medical Accommodation Form

Form Instructions for Printing

Attestation Form

• At the MS and HS level, if a student is going to self-carry and self-medicate, the Attestation Form must be completed and submitted to the health office. 
• Please return or E-mail completed form to the school nurse.

Attestation Form

Medication Authorization Form 

• A NYS healthcare provider must fill out the Medication Authorization form for all medications to be given in school, including over the counter medications.
• All medications must be provided in original packaging.
• All medications including over the counter and prescriptions, must be delivered to the health office by a parent or designated adult.
• Please return or e-mail completed form to the school nurse.

Medication Authorization Form

Form Instructions for Printing

Medical Home Instruction

• If your child will be out of school for an extended period of time (for 14 days or more) due to a non-communicable illness or recovering from an injury, please have your healthcare provider fill out the Medical Home Instruction Form. Please make sure the form is fully completed and is signed and stamped by the healthcare provider. The form will be reviewed by the school physician and is subject to approval.
• Please return or e-mail completed form to the school nurse. 

Medical Home Instruction Form

Form Instructions for Printing

New Entrant Registration Packet

Mandated NYS Physical Examination

• NYS Education Law Article 19 requires students who are entering the school district for the first time to submit a current and complete physical exam performed within a year of the school year. Student’s medical concerns, fragile medical conditions, or social– emotional issues may impact their ability to participate fully in school. It is important to have this information prior to school entrance to help with the student’s condition that requires routine or emergent care by school personnel.
•  A health examination can only be performed by a NYS private health care provider, a licensed physician, physician assistant, or nurse practitioner. Each certificate or appraisal must be signed and stamped.

Student Health History

• The health history for new entrants should be completed by the student’s parent or guardian. A comprehensive health history includes but is not limited to: Current status of the student’s health problems, serious or life-threatening conditions, allergies, chronic illness and medications, accident or injuries, and psychosocial factors that may affect the student’s school performance. 

Student Health History Form

Dental

• NYS recommends having information regarding the student’s oral health. The dental exam can only be performed by a NYS licensed dentist. The form must be signed and stamped.

Dental Form

Immunization Record

• The immunization record is obtained form your health care provider
• New York State Public Health Law, requires that a child not be permitted to attend school unless the parent provides the school with a certificate of immunization or proof from a physician, nurse practitioner or physician's assistant that the child is in the process of receiving the required immunizations. The exact date each immunization was given must be included in the record. Each record must be signed and stamped. The immunization record must be submitted within 14 days of the first day of school. For students entering school from another country this record must be received within 30 days of the first day of school. 
• View NYS mandated immunizations for school entry.
• Please return or e-mail completed form to the school nurse.

Form Instructions for Printing

Interscholastic Sports Clearance

• Students must have an updated and completed physical exam on file. This is required to protect the health and the safety of students before participation.
• The NYS Physical Examination Form is the only approved form for interscholastic sports. A physical exam is valid for 12 continuous months - through the last day of the month in which the exam was conducted.
• The physical exam form can be found at here and must be submitted to the nurse or uploaded to the student’s family ID account.
• Athletic registration is done online at the Family ID website. Check out our step by step instructions.
• The registration and Health History for Athletics must be completed and signed by the parent/guardian 30 days before the start of the season.
• Please return or e-mail completed form to the school Nurse.
• Before each athletic season, the school nurse will review and verify the completion of all health requirements for each student. Any student who fails to provide the necessary documentation will not be granted clearance to participate in that season. All participation is subject to approval by the school nurse.

 Check out sports season by grade level.

Form Instructions for Printing