Medical Forms

Athletic Physical Form

Permission for Medicine at School

Permission for Medicine at School Form (Word format)

Permission for Medicine at School

Permission for Medicine at School Form (pdf format)

Permission for Self-Administration of Medication

Permission for Self-Administration of Medication Form (pdf format)

Permission for Self-Administration of Medication

Permission for Self-Administration of Medication Form (Word format)

Required Immunizations

• Diphtheria, Tetanus, Pertussis (DTaP): five (5) doses required. Four doses acceptable if dose 4 given on or after the 4th birthday. A single dose of Tdap required at grades 7-9 grade if no previous history of Tdap vaccination regardless of interval since the last Td vaccine.
• Poliomyelitis (IPV/OPV): four (4) doses required. One dose required after age 4 regardless of the number of previous doses, with a 6 month minimum interval from the previous dose
• Measles, Mumps, Rubella: two (2) doses required.
• Hepatitis B: three (3) doses required through grade 11.
• Varicella (chickenpox): two doses required for grades K-2 and 7; one dose required for grades 3-6 and 8-11 unless history of varicella disease documented by a licensed physician. Two doses are currently recommended by the ACIP for all ages.
• Haemophilus influenzae type b (HIB): three doses required for children less than 5 yrs of age in early childhood programs. Total doses needed for series completion is dependent on the type of vaccine and the age of the child when doses given.
• Pneumococcal conjugate (PCV7): four doses required for children less than 5 yrs of age in early childhood programs. Total doses needed dependent on the age of the child when doses given.
• Hepatitis A: two doses required for children less than 5 yrs of age in early childhood programs.

[Additional Immunization Information]

Vision, hearing and dental screenings are provided each year at selected grade levels and upon request. The school nurse and nurse aides will notify a parent only if screening results are not within normal limits.

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In order for children to receive medicine while at school, the forms (at left) must be appropriately filled out and returned to the school prior to its administration. Each request expires at the end of the current school year.