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Health Forms
Here you will find the various forms that we use in the
Nurse's Office. Please follow the directions specific to
each one. Some forms may be filled out on-line, but all
forms must be printed and delivered to the Nurse's Office in
order to be on file.
You will need the free
Adobe Reader to access any of these forms. For
any form that is available for on-line completion, you
should place your cursor in the text area where you would
normally write and left-click once. Begin typing as normal,
and when you are finished with that field, you should click
anywhere outside the text field, or just hit Enter. You may
Tab through each field if you desire. You may always return
to a field to edit your previous entry.
Forms may be mailed or delivered directly to the School
Nurse. It is important the forms are not sent or delivered
to another department to ensure forms are obtained in the
appropriate time frame. You may also fax the forms to
(919)677-8670, attn: School Nurse. Contact the School
Nurse at (919)228-4562 or
Judy_Rodocker@caryacademy.org if you have any questions
(please contact me per e-mail during the summer months, as I
am not in the clinic). Again, it is strongly suggested that
you make copies of the submitted forms in the event a form
is misplaced or lost. The appropriate forms (physical,
liability and medical history) are also shared with the
Athletic Trainer for the students. Please comply with the
due date of August 1st of each year for all required forms
(except physicals due at different times in the school
year-all other forms are expected to be turned in prior to
the beginning of the school year). Thank you in advance for
your assistance in this important matter.
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Form Name |
Explanation |
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Cary
Academy Medical Forms Checklist:
Adobe PDF Version
MS Word Version
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The Medical Forms Checklist was
designed to assist you in determining the specific
forms needed for your child at the beginning and/or
during the school year. Please refer to the forms
checklist and complete the necessary forms specific
to your child.
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Form Name |
Explanation |
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Liability:
Adobe PDF Version
MS Word Version |
Liability/Insurance Form:
The completion of the liability/insurance form is
required each school year for all Cary Academy
students. This form can be completed
electronically or by hand, printed and signed by the
parent/guardian before returning it to the CA
School Nurse by August 1st of each
school year. ** Please complete all
sections of the form.
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Medication
Administration Form:
Adobe
PDF Version
MS
Word Version |
Medication Administration Form:
The Medication Administration Form is required
yearly for any student who may receive or take
non-prescription (over the counter) and/or
prescription medications during school hours or a
school related activity by the School Nurse, her/his
designee or by self. Over the counter medications
are available in the school clinic (please review
the form for the medications offered at school.
This form is to be completed for non-prescription
and prescription medications by the physician and
signed by both the physician
(or designee) and the parent/guardian. This is in
compliance with NC State law and Nurse Practice
Act. No medication (non-prescription or
prescription) will be administered without a
physician’s order (or designee) and signatures of
the physician (or designee) and the parent/guardian.
It is required that any medication brought to the
school should be in the original container with
instructions on administration and dosage. A
student who self carries any medication is to have
the form authorized by the physician and signed by
both the physician and parent/guardian. All forms
are to be submitted to the School Nurse at the
beginning of each school year.
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Physical:
Adobe PDF Version
MS Word Version |
Physical:
A physical by a physician (Nurse Practitioner or
Physician Assistant) is required for all new
students, as well as, annually for all athletes
participating in organized school sports. It is
imperative that the physical on file for athletes be
current (within a year). It is suggested you keep a
copy of the physical for your files so that there is
no lapse in the yearly physical coverage. This
should assist in scheduling the physical
accordingly. The physical is to be completed and on
file with the School Nurse for the
new student by the beginning of the school year
and for any student athlete, by the next due date,
to keep the physical current.
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| Medical History and
Student Health Assessment Form:
Adobe PDF Version
MS Word Version |
Medical History and Student Health Assessment:
This form is to be completed by the Parent/Guardian
on a yearly basis for all students to assure
all medical information is up to date, including new
or changes in any medications.
Please complete and sign the form and submit it to
the School Nurse by August 1st of each
school year. It is very important to inform the
School Nurse of changes in medical conditions or
medications throughout the school year in order to
provide optimal care for the student.
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The Following Forms are only to be completed if it pertains
to your child:
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Form Name |
Explanation |
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Immunization:
Adobe PDF Version
MS Word Version |
Immunization:
Please read carefully due to changes in NC
Immunization Law, effective January 1, 2008-
State law G.S. 130A-152 requires proof of
immunization for every child present in North
Carolina. Evidence of immunization is required
for all new students within 30 calendar days from
the first day of attendance at Cary Academy.
Please forward updates in immunizations during the
past school year for a returning student.
This form should be taken to the physician of the
student so it can be completed.
Update in NC Law:
Effective January 1, 2008, the administrative rule,
10A NCAC
41A.0401, has been changed, adding requirements
for one
booster dose of Tdap (tetanus/diphtheria/pertussis)
vaccine to be given to the following age groups:
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All individuals attending public school who are entering the 6th
grade on or after August 1, 2008, if
five
years or more have passed since the last
dose of tetanus/diphtheria toxoid
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All individuals not attending public schools (i.e., private,
home-school, non-traditional schools)
who are 12 years of
age on or after August 1, 2008, if five years or
more have passed since the last dose of
tetanus/diphtheria toxoid.
- Individuals enrolling
in college or university for the first time on
or after July 1, 2008.
This administrative rule change
also impacts
mumps vaccination.
Individuals will now be required to receive a
second dose of mumps vaccine before enrolling in
school, college or university for the first time on
or after
July 1, 2008.
It is also suggested you speak
with the physician about the Meningococcal Vaccine
recommended by the CDC for ages 11-12 years or those
entering the ninth grade and also the new vaccine,
Gardasil, which helps prevent the Human
Papillomavirus.
Please make certain your child is current on
all vaccines, including Tetanus, which is now
recommended every five (5) years.
The Immunization Form should be forwarded to
the CA School Nurse within the required timeframe.
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| Medical Clearance
for Return to Physical Activity Form:
Adobe PDF Version
MS Word Version
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Medical Clearance For Return to Physical Activity
Form:
This form is to be completed by your physician to
allow your child to resume participation in physical
activity (sports, PE, etc.) following restrictions
due to surgery, injury or other medical conditions.
It is not necessary to complete this form for all students.
Please submit to the School Nurse.
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| Asthma Action Plan:
Adobe PDF Version
MS Word Version
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Parent/Guardian is to
coordinate an action plan with the School Nurse for the
student diagnosed with Asthma. The completed plan of action
will be on file in the School Nurse Office. Appropriate
Faculty/Staff will have access to the plan in event of an
emergency.
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| Severe Allergy
Action Plan:
Adobe PDF Version
MS Word Version
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Parent/Guardian will coordinate an
action plan with the School Nurse for the student
diagnosed with severe allergic reactions. The
completed plan of action will be on file in the
School Nurse Office. Appropriate Faculty/Staff
will have access to the plan in event of an
emergency.
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| Diabetic Action
Plan: |
Parent/Guardian is to coordinate an
action plan with the School Nurse for the student
diagnosed with Diabetes. The completed plan of
action will be on file in the School Nurse Office.
Appropriate Faculty/Staff will have access to the
plan in event of an emergency.
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Specialized Health Care Form for Parents:
Adobe PDF Version
MS Word Version
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Specialized health care forms should be filled out if a
student requires any specialized health procedure(s) or care
while at school. Form should be filled out electronically
or by hand, printed out, and signed by a parent/guardian and
a physician if appropriate before returning to the School
Nurse.
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Specialized Health Care Form for Physicians:
Adobe PDF Version
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Specialized health care forms should be filled out if a
student requires any specialized health procedure(s) or care
while at school. Form must be printed out, filled out by
hand, and signed by parent and/or physician where
appropriate before returning to the School Nurse.
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| Release of Medical Information Form:
Adobe PDF Version
MS Word Version
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Please print and complete this form
if you would like us to release medical information
from your child’s medical file. After
completion of the form, please submit the form to
the School Nurse.
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