Health Office Forms

EpiPen

For a child to have an EpiPen in school, the following must be completed:

Your child’s physician must complete and sign the Anaphylaxis Emergency Care Plan.
The Parent/Guardian must sign the bottom of the Anaphylaxis Emergency Care Plan (remember to indicate on the bottom of the form if you wish for your child to sit at a peanut/nut free table at lunch).
EpiPens must be in the prescription labeled box and hand delivered to the school nurse by the parent/guardian.

Anaphylaxis Emergency Care Plan

Asthma Inhaler

Medications at School

For a child to take a prescription or nonprescription medication at school, the following must be completed:

Your child’s physician must complete and sign the Medication Authorization Form.
The parent/guardian must sign the bottom of the Medication Authorization Form.
All medications (prescription or non-prescription) must be in its original container and properly identified and hand delivered to the school nurse by the parent/guardian.
Your child MAY NOT carry medications with them to school.

Medication Authorization Form

Concussions

Entrance Physical Form

Written proof of a physical examination is required of each child upon entering school in the district. Within 365 days of the first day of school for those entering school for the first time or transferring to Medford Township School District from out of state. The physical should be documented and signed by your physician on the Medford School District History and Physical form. This form is located below.

History and Physical Form