2023 - 24 – Health Office Forms and Information

 Return all completed health forms promptly! 

 The information contained in this document includes live hyperlinks.  The online form is accessible using the following web address.  

 “SEYMOUR HIGH SCHOOL STUDENT DEMOGRAPHIC and HEALTH EMERGENCY INFORMATION”:

This form is important and is required – we need to be able to reach you or a contact person immediately in case of an emergency, accident or illness that arises during school hours. The phone numbers need to be current, and the information of local contacts needs to be included. Make arrangements in case your child needs to be picked up due to an unexpected early dismissal. Complete, sign, and return it to the main office promptly.

 “Tylenol and Ibuprofen Permission”: A new form is required every school year

Signed parent/guardian permission on this form is required in order for the Seymour High School nurse to administer this medication to your child if the need arises. Only a nurse may administer this medication with this standing order. 

This form is not for field trips. The form “Authorization for the Administration of Medicine by School Personnel” needs to be completed if necessary. Refer to the next form. 

  “Authorization for the Administration of Medicine by School Personnel”: A new form is required every school year

This form is required for all prescription and over-the-counter medications if dosages and frequency of Tylenol and Ibuprofen are different than those on the above-mentioned permission form, and if Tylenol or Ibuprofen is necessary during a field trip. 

•  “Food/Insect & Emergency Allergy Care Plan and Medication Authorization”

• “Asthma Action Plan & School Medication Authorization”

• "Seizure Action Plan"

: A new form is required every school year

These care/action plans include the medication order(s), no additional medication form is required. They are also required for a student to self-administer prescribed emergency medications-asthma rescue inhalers and Epinephrine cartridge injectors for medically-diagnosed allergies.

 Does your child have health insurance? For insurance information use the link below.

“Access Health CT- Connecticut’s Health Insurance Marketplace”  “HUSKY HEALTH Connecticut”:

 Physicals:

 Physicals must be recorded on the “State of Connecticut Department of Education Health Assessment Record Form” (three pages, commonly referred to as the “blue” form).

• The first page is completed by a parent or guardian before the child’s appointment. 

• The asterisk (*) indicates the mandatory screenings/tests to be completed by the Health Care Provider under Connecticut State Law. 

 Note: Some of the immunization requirements have changed since the Revised 4/2012 printing. The current requirements for high school age students are accessible using the link below.

 All students must meet the current State Of Connecticut, Department Of Public Health Immunization Requirements For Enrolled Students In Connecticut Schools 2022-2023 School Year.

 For the full legal requirements for school entry use the following link – “School Immunizations Requirements”.

 New Entrants: 

 See the definition of “New Entrant” that is included with the current immunization requirements (refer to above). All new entrants need to have a current physical done by a legally qualified healthcare provider and be up to date according to current Connecticut immunization requirements. This information needs to be documented by the health care provider on the “State of Connecticut Department of Education Health Assessment Record Form”  (refer to physicals above).

 Students Entering Grade 10:

 All sophomore students need an immunization update and a current health assessment. The “State of Connecticut Department of Education Health Assessment Record Form”  (refer to physicals section above)

 Athletes:  

 Athletes are required to have an annual health assessment.  The completed “State of Connecticut Department of Education Health Assessment Record Form”  must be submitted to me in advance of any sports participation including tryouts/conditioning.  A physical is good for 1 year from the date of the exam.  All students registering for sports in Seymour High School must register through familyID, please read the athletic director's instructions to register for sports.  “Familyid instructions”

 Be sure to schedule physicals now, retain a copy of the completed “State of Connecticut Department of Education Health Assessment Record Form”  for your records, then forward the completed form to:

School Nurse

Seymour High School

2 Botsford Road

Seymour, CT  06483

Submit all health forms promptly, throughout the summer, and they must be received at the start of the school year.   

Health forms and information are available in the Student/Parent Handbook under Nurse/Medical which is located on the internet at https://www.seymourschools.org/district-departments/health-services.  

Please contact the main office if you have any questions or concerns that we need to address.

I wish everyone a safe and healthy summer, and I look forward to working with you and your child in the upcoming school year!  

Thank you for your anticipated cooperation.

 Sincerely,

  SHS Nursing Office

Seymour High School

(203) 881-7531, (203) 888-2561 x1094