• FORMS

    PHYSICAL FORMS

     

    Physical Examination Form - Pursuant to N.J.A.C. 6A:16-2.2, this form is to be completed by your child’s physician and is required upon enrollment into school. Subsequent medical examinations for your child are important and encouraged at least one time during each development stage:  early childhood, pre-adolescence, and adolescence.

     

    Annual Athletic Pre-Participation Physical Evaluation Forms – Pursuant to N.J.A.C. 6A:16-2.2h, these forms are to be completed by physician, parents/legal guardians, and athlete and are required for a student to participate in athletics.  Click below for link to CHS Athletics Department and forms.
     
              

    IMMUNIZATION FORM

     

    Certificate of Immunization – This form, to be completed by your child’s physician, is required upon enrollment into school pursuant to N.J.A.C. 8:57-4, Chapter 14 of the New Jersey Department of Health and Senior Services Regulations which requires that New Jersey pupils be immunized against certain communicable diseases.

     

    MEDICATION AUTHORIZATION FORMS

      

    Request for Administration of Medication - Pursuant to N.J.S.A. 6A:16-2.3(a) 3vii, this form is to be completed by your child’s physician and parent/legal guardian when a prescribed medication - including over the counter medication - needs to be administered to your child by the school nurse during school hours.

     

    Request for Self-Administration of Medication - Pursuant to N.J.S.A. 18A:40-12.3 and 12.4, this form is to be completed by your child’s physician and parent/legal guardian when your child is permitted to self administer medication for a potentially life threatening condition as defined by the Department of Education.

      

    Asthma Treatment Plan – Pursuant to N.J.S.A. 18A:40- 12.3, this form is to be completed by your child’s physician and parent/legal guardian when your child uses asthma medication or a nebulizer during school hours.

     

    PERMISSION FORMS

     

    Permission for Designees for Emergency Administration of Epinephrine – Pursuant to N.J.S.A. 18A:40-12.6, this consent form is to be completed by the child’s parent/legal guardian for the school nurse to train volunteer staff members to administer epinephrine via a pre-filled auto-injector to your child for anaphylaxis when the school nurse is not available. 

     

    Permission for Designees for Emergency Administration of Glucagon - Pursuant to N.J.S.A. 18A:40-12-11-21, this consent form is to be completed by the child’s parent/legal guardian for the school nurse to train volunteer staff members to administer Glucagon to your child for severe hypoglycemia when the school nurse is not available.

     

    Parent Guardian Permission to Release & Exchange Confidential Information - Pursuant to N.J.A.C. 6A:32-7.4, this consent form is to be completed by the child’s parent/legal guardian to allow exchange of information to occur between the child’s physician, the school nurse, and appropriate school personnel - on a need-to-know basis – regarding any medical conditions your child may have.

Last Modified on June 9, 2017