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, Mrs. Phyllis Kollar, is available with any questions you might have. She can be reached at: (201) 358-4016 ext. 1020 or pkollar@rivervaleschools.com

 

Annual Physical Examination             Required for all students. Must use the state physical form. Valid for 365 days  Annual Physical Examination 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
State Mandated Athletic 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:


Concussion and Head Injury Fact Sheet

Sudden Cardiac Death in Young Athletes Pamphlet

Sports Related Eye Injury Fact Sheet

Opioid Use and Misuse Fact Sheet

Valid for school year

(ALL students need new form for Spring 2018 to comply with new state regulations)

State Mandated Athletic 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
       

 

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