Forms & Action Plans

Forms and action plans ensure clear communication and set expectations among school nurse professionals, medical providers, and families.  Use the following section to access these important resources.  

Reach out to your child's school nurse if you have any questions or concerns.

Medical Forms:

State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school. The parent or guardian completes Part I of the form. The Medical Provider completes Part II and Part III of the form. 

This form must be completed no earlier than one year before your child’s entry into school.

The Medication Permission Form is required if your child will be taking medication on a daily basis in the school clinic.  It requires signatures by a parent/guardian and the Medical Provider.

This form is an affidavit stating that the administration of immunizing agents conflicts with the student's religious tenets or practices, and must be notarized before being submitted to the school.

Medical Care Plans:

The following plans provide essential information for our health services staff to properly administer treatments and medications prescribed by your child's Medical Provider.  Contact your child's school nurse if you have any questions.

Miscellaneous Resources:

Preventing the Spread of Respiratory Viruses (Flu, COVID-19, RSV):

You can go back to your normal activities when, for at least 24 hours, both are true: