Medical Forms

Medical forms for students, both new and returning

• Forms needed to enter school in the fall
  

  Letter from school nurse.

• Authorization for Medication
  

  Letter & Form for Over the counter treatment.

  Dear Parent/Guardian,
  New York State Education Law has requirements for students and medication in school Both a
  written order from a licensed provider and written parental permission are necessary for any
  medication given in school and/or during school activities. This includes Over-the-counter
  topical first aid applications such as calamine lotion, vaseline, antibiotic ointment, antiseptic
  wash etc. and prescribed medications such as Epi pens, inhalers, insulin etc. This permission
  must be renewed on an annual basis.
  If you would like your child to have access to Over-the-counter topical treatments or if they will
  require any other medication during the school year, please have your licensed provider
  complete the provider section on the Authorization for Medication forms.
  The medication should be delivered by a responsible adult (not the student) to the Health Office
  in a properly labeled, original container. Most pharmacists will divide prescription medication
  into two containers if you request this. Over-the-counter medications must be in the original
  manufacturer’s container with the student’s name affixed to the container. All medications must
  be picked up at the end of the school year.
  If your child needs to carry and administer his/her own medication at school and school
  activities then the licensed provider must attest that your child has demonstrated capability to
  Independent Carry and Self-Administer on the medication form. The category
  Self-Administer with Staff Supervision allows students to administer his or her own
  medication, under the direction of an unlicensed staff member, at school or school activities
  such as sports practice and field trips without the presence of a school nurse.
  Incomplete forms will not be accepted. If you have any questions or concerns please contact
  your child’s school nurse. Thank you for your attention to this matter.
  Sincerely,
  Tracey Ferreri, LPN
  tracey.ferreri@uptonlake.com

• School health exam form
  

  3 page form, please print all 3 pages.

• Immunization Requirements
  

  2 pages, please print both pages.

• Self carry medication
  

  1 page form.

• Food allergy action plan
  

  You may submit a form from your allergist instead, if the doctor prefers.