Health Forms
All student health forms required by Holdrum Middle School are outlined below. Please read through each form description carefully, as some are mandatory for all HMS students, while others only apply to athletes or students with specific medical issues. Our school nurse, Ms. Phyllis Gerber, is available with any questions you might have. She can be reached at: (201) 358-4016 ext. 1020 or Email Phyllis Gerber.
Forms/Documents/PDF
Annual Physical Examination | Required for all students. Pages 1-4 of this document is to be kept on file at your child's doctor's office. Only Page 5 is to be returned to HMS | Valid for 365 days from exam | Annual Physical Complete Packet |
PPE Medical Eligibility Form | This is the only medical form signed by your doctor that should be handed into HMS. This form is also included in the packet linked above titled: Annual Physical Complete Packet. | Valid for 365 days from exam | PPE Medical Eligibility Form |
Immunizations: Tdap (Tetanus, Diptheria, Pertussis) and Meningococcal | Required for all students. Must provide record of immunization, which can be obtained from child's doctor. | ||
Health History Update | Required for students trying out for a sport (including the bowling and golf clubs and intramural activities). Must be completed for each season. | Valid for 90 days | Health History Update Questionnaire |
Athletic Permission & State Mandated Fact Sheet Signoff | Required for students trying out for a sport(including the bowling and golf club and intramural activities). Must circle all sports student is interested in trying out for. To be signed after reviewing the following Fact Sheets: | Valid for school year | Athletic Permission & State Mandated Fact Sheet Signoff |
Medication Authorization | Required for any students who may need to receive medication during the school day, this includes self administering medications such as auto-injectors, inhalers, and diabetics. | Valid for school year | Medication Authorization Form |
Allergy Action Plan | Required for any student who has an allergy and may need an epi-pen and/or special accommodations in school. This includes food allergies. | Valid for school year | Allergy Action Plan |
Asthma Action Plan | Required for any student who requires asthma medication while in school. | Valid for school year | Asthma Action Plan |
Seizure Disorder Action Plan & Parent Questionnaire | Necessary for any student with a seizure disorder | Valid for school year | Seizure Disorder Action Plan |
Seizure Disorder Parent Questionnaire | |||
Dental Form | To be filled out when student goes to the dentist | As applicable | Dental Form |