Health Services Forms
Listed below are the Health Services forms most commonly used. To print the form, click on the name below and print. If you have any questions about completing the form, please do not hesitate to contact your child's school nurse.
Emergency contact information is now done by the parent/guardian through Tyler SIS at the beginning of the academic year. Once notification is sent out that this portal is open, information should be updated as soon as possible. The update of information cannot be done via a tablet or phone through the app. It is essential that the Health Services staff can reach you in case your child is ill or injured. In addition, an emergency form will be sent home with the student in the first few days of school. The emergency form must be completed and signed by the parent/guardian indicating permission for use of over the counter analgesics, and returned to the school nurse immediately. If throughout the school year any changes need to be made after the portal has closed, please contact your school nurse or send in the linked form to the school Health Office.
Medication Permission Form
This permission form should be completed when requesting medication be dispensed to your child during the school day.
Camp KOK Medication Form
This permission form should be completed when requesting medication to be dispensed to your child during Camp KOK.
Allergy Action Plan
This form should be completed by you and your child’s physician indicating the steps to be taken if your child has a life threatening allergy. It’s important to note that if Zyrtec or Benadryl are a part of the plan, the physician should include the written prescription for that medication.
Please note that the district has Epinephrine available in all the District Health Offices, in case of an emergency. The Pennsylvania Public Code School Code Section 1414.2(g) allows parents/guardians to request an exemption to the administration of an epinephrine auto-injector for their child. In order to request this exemption, contact the school nurse to make an appointment to discuss this decision, review, and sign the opt out form.
Asthma Action Plan
This form should be completed by you and your child's physician indicating the steps to be taken if your child has an episode of asthma.
Physical Exam Form
This form should be completed by your child's Primary Health Care Provider for entry into school (Kindergarten or 1st grade), before starting 6th grade, and before starting 11th grade.
This form should be completed by your child's dentist for entry into school (Kindergarten or 1st grade), before starting 3rd grade, and before starting 7th grade.
Print this form when sending in an excuse for your child's absence. A written excuse is required for each absence.
NA Physical Education Can Do List
This form can be used for the health care provider to specifically list what can be done in PE if restrictions need to be in place.