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Medical Forms

 


REQUIRED FOR ALL INCOMING STUDENTS (FRESHMEN & TRANSFERS): 

ALL STUDENTS: IMMUNIZATION RECORDS print-out from physician's office. 

Note for out-of-state students: NJ requires 1 dose of TDAP vaccine after age 10 and 1 dose of Meningococcal Vaccine for students born after 1/1/97.  If you have only attended NY schools you may not have received these vaccinations.

ALL STUDENTS:  Ma'ayanot Health Form.  Must be signed by physician and her last physical exam performed within the past year, i.e. after 9/1/2015.  NOTE:  If your healthcare provider's office provides a comparable health form or you have a comprehensive camp health form, those would be acceptable alternatives to our health form.

STUDENTS WITH ASTHMA: Asthma Treatment Plan.  Note: Form expires after 1-year of physician's date and must be resubmitted at that time.

STUDENTS WITH EPI-PEN / FOOD ALLERGIES: Allergy Action Plan

STUDENTS WITH MEDICATIONS: Medication Administration Form.  This form is required for students who take medications on a regular basis and also gives permission for students to self-administer meciations in school and/or for medications to be stored in school or administered by the school nurse in the event the student is unable.  Must be completed annually.

STUDENTS WITH SEIZURE DISORDER: Parent Questionaire for Seizure Disorder, Seizure Action Plan

 

STUDENT ATHLETES:

  1. PreParticipation Athletic Form (4 pages).  Must be completed by parent (page 1) and physician (pages 2-4).  Last physical exam performed within 365 days of first practice.  Please submit directly to school nurse.
  2. Health History Update.  To be completed by parent if Athletic Form (listed above) is older than 90 days before first practice.
  3. Sudden Cardiac Death in Young Athletes Pamphlet.  To be read by all student athletes and their parents
  4. Sudden Cardiac Sign-off Form.  To be signed by all student athletes and their parents after reading pamphlet (#3 above)
  5. Concussion Fact Sheet.  To be read and signed off by both student athlete and parent.
  6. Sport-Related Eye Injuries.  To be read by athletes and parents.  No action needed.

For explanation of above forms, who can complete them and by when, expiration dates, and nurse guidelines, click here.