Forms

Anaphylaxis Form, Addendum to Medical Form

This form is to be used along with the Self-Medication Authorization form. Its purpose is to define the sequence of emergency responses as directed by the student's Physician for a Severe Allergic/ Anaphylactic Reaction.

Authorization for the Administration of Medication

The form for the Authorization for the Administration of Medication should be used for any medication that your student should receive during the school day. No medication is permitted to be given without this authorization including over-the-counter medication.

If clarification is necessary please contact the Health Room Office.

Authorization for Self-Administration of Medication

If a student requires an Inhaler for asthma or an Epi-Pen for severe allergic reactions it is suggested that a Self-Administration Medication form be completed by the student's Medical Practitioner. The rationale is that the delivery of the medication will be expedited in a more immediate time frame and the student will be equipped for an emergency while on a school sanctioned field trip or during after school activities.

If your student requires an Epi-pen for a severe allergic reaction, they should also include the Anapylaxis form along with this Self-Administration of Medication form.

If clarification is necessary please contact the Health Room Office.

Health Assessment Record

The State of Connecticut requires a health assessment in 9th or 10th grade. No student may go on to 11th grade without satisfying this requirement. If a student does not play a sport, this health assessment is the only one they will need during their High School career.There are asterisks on the State Health Assessment form that denote required screenings. One such screening is the HCT/HGB which must be completed for the assessment to be acceptable.

If a student plays a sport, a health assessment will be required yearly. The health assessment that they receive for the State requirement may be used to satisfy the sport's requirement and vise versa as long as the mandated screenings are satisfied. If one's physical is for sports one would not need an HCT/HGB screening. If one's physical was for the 9th or 10th grade State mandated physical one would require the screening.

You may download this form for the 9th or 10th grade mandated health assessment or for any sport participation.

Please call the Health Room Office for clarification if needed.

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