TO: Parents / Guardians
FROM: Dianne Donohue-Hand, RN, MA, CSN
RE: HEALTH & PHYSICAL FORMS FOR THE SCHOOL YEAR 2015-2016
Below are forms for your child to be completed for the School Health Office.
- Asthma Action Plan – If your child has a history of asthma, or uses an inhaler, or a nebulizer please have your physician complete the form for self-administration and signed by a parent.
- Allergy Form – If your child has allergies and is prescribed Epinephrine, please have your physician complete the form for self-administration and signed by a parent.
- Medication Form – If your child needs to take medication daily during the school year, or you want to have medication in school for your child, such as Tylenol or Cough Drops, or any other over the counter medication, a medication form needs to be completed by your physician and signed by a parent and a parent must bring the medication to school.
No medication can
be administered without a doctor’s order and parent consent. All
medication must be brought to the nurse
by an adult in the original container with the students name, the medication
name and dose to be given, and the doctor’s name clearly on the container.
- No Longer Medical Condition - If
your child no longer needs medication for any known medical condition,
have the doctor complete this form.
- Athletic Pre-Participation Physical Form – This is
a mandatory physical required for all seventh graders. The physical is also required for any
student who wishes to participate in any extracurricular sports program. New for the 2015-2016 School Year: any
doctor completing a Pre-Participation. Physical must provide
the date of completion for the Cardiac Assessment Professional Development Module or the
physical is not valid. New: any doctor completing a Pre-Participation
Physical must provide the date of completion for the Cardiac Assessment
Professional Development Module or the physical is not valid. Doctors from out of state, such as New
York or Connecticut must also complete the Professional Development Module.
FAXED PHYSICALS WILL
NO LONGER BE ACCEPTED
- Health History Update Form – This form must be completed if any student who wishes to participate in any extracurricular sports program and their sports physical is over 60 to 90 days old.
- Permission to Share Information – If your child has any medical conditions, this form gives me permission to share pertinent medical information with other school personnel; to protect the health and safety of your child.
- Guidelines on when to keep your child home.
Any student that has a medical condition that needs medication such as an Inhaler or an Epi-Pen and does not provide a doctors order and the medication will not be allowed to participate in sports or be allowed to participate in Field Trips.
The above forms may be downloaded from the LMS website from
the School Nurse Link located at the top of the webpage under the drop down
menu for departments and programs.
Injuries: CASTS, SLINGS, SPLINTS, and CRUTCHES
If your child is returning to school with an injury, please obtain a doctor's
note for the use of CRUTCHES and use of the elevator: The note must clearly
state that the student is allowed to use crutches in school, and to allow the
student to the use of the elevator. It
must also state the nature of the injury, expected time of recovery, and dates
the student is excused from physical education and sports.
If you have any questions or you would like to discuss any
health issues your child might have, please call Ms. Donohue-Hand at 201-302-5200,
ext. 3209. You may mail or drop off
forms to the attention of Ms. Donohue-Hand, School Nurse at Leonia Middle School,
or you may email them to me at firstname.lastname@example.org.