KP HEALTH AND SCHOOL NURSE
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FORMS

This page contains forms that are also found on the School Requirements page, as well as forms for medication administration, common health concerns in the school setting, and emergency contact information update. 

Immunization / Dental Screening / Vision Screening Forms

Certificate of Immunizations
File Size: 112 kb
File Type: pdf
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Certificate of Dental Screening
File Size: 171 kb
File Type: pdf
Download File

Vision Screening Form
File Size: 105 kb
File Type: pdf
Download File

Certificate of Immunizations- Medical Exemption
File Size: 235 kb
File Type: pdf
Download File

Certificate of Immunizations- Religious Exemption
File Size: 200 kb
File Type: pdf
Download File

Certificate of Dental Screening-Exemption
File Size: 147 kb
File Type: pdf
Download File


Medication Administration Form

This form has been updated as of February 2018. It requires that a doctor fills out the bottom half of the form for any medication that is prescribed and to be given at school. If your doctor has their own form that is also acceptable- a parent signature may still be required. Please print this form and take it with you to your doctor's appointment. One form is needed for each medication. 
Medication Authorization Form
File Size: 22 kb
File Type: docx
Download File


Emergency Contact & Health Form 
​ Health History Form (kindergartners & new students)

health_safety_emer_form_18_19.pdf
File Size: 107 kb
File Type: pdf
Download File

Health History Form
File Size: 20 kb
File Type: docx
Download File


Common Health Concerns

Health diagnoses that are considered common in the school setting include asthma, allergies, diabetes, and seizure disorders. If your student has been diagnosed with one of these conditions, or something else, please print off the corresponding form and have the doctor fill it in at your next appointment. If a medication is prescribed for the condition a medication administration form will also need to be filled out by your child's doctor.
Food Allergy Care Plan
File Size: 629 kb
File Type: pdf
Download File

Food Allergy Diet Modification Packet
File Size: 435 kb
File Type: pdf
Download File

Asthma Care Plan
File Size: 103 kb
File Type: pdf
Download File

Diabetes Care Plan
File Size: 94 kb
File Type: pdf
Download File

Seizure Care Plan
File Size: 272 kb
File Type: pdf
Download File

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