FOOD ALLERGY AND
MEDICAL CONDITION REQUEST FORM

Student Emergency Form

Each student must have a physical examination within one year prior to trying out for any sport. It is recommended that a student-athlete have his/her physical examination administered by their family physician.

Physical Form Immunizations

Entry into
Kindergarten

• DTaP/DTP - 5 doses
• Polio - 4 doses
• MMR - 2 doses
• Varicella - 2 doses
  OR physician certified history of chicken pox
• Hepatitis - 3 doses - birth or first dose- 1 month after first dose- 6 months after first dose
• Lead Screening
• Physical exam done by primary care provider
• Vision Screening - including stereopsis*All copies should be sent to School Nurse.
  To print out forms to bring to the physicians office
• IMMUNIZATION FORM
• PHYSICAL FORM

*Stereo E test plate with an array of dots that appear randomly oriented, but when viewed through the stereo glasses a large letter "E" will appear if the child has normal binocular vision.

DTaP/DTP ≥ or 3 Td + 1 Tdap

All copies should be sent to School Nurse.To print out forms to bring to the physicians office click here:

• IMMUNIZATION FORM
• PHYSICAL FORM

DTaP/DTP - 4 doses or 3 doses Td plus 1 dose Tdap

- 6 months

Physical exam - Seventh grade

• Tenth grade
• SPORTS physical each year of participation before tryouts
• All copies should be sent to School Nurse.
  To print out forms to bring to the physicians office, click here:
• IMMUNIZATION FORM
• PHYSICAL FORM

Required physicals: Preschool/kindergarten, Grades 4, 7, 9
Vision: Grades K-5, 7, 9 & referrals as needed
Hearing: Grades K-3, 4, 7, 9 & referrals as needed
Postural screening in Grades 5 - 9
Annual height and weight (Body Mass Index) in Grades 1, 4, 7, & 9
Interval health histories

DAILY SCREENING

• Communicable disease (doctor's note required)
• Five day absences (doctor's note/school nurse clearance required for re-entry)
• Follow up referrals
• Student illness referrals

Freshman Health Screening Day takes place in the spring, in the BHS locker rooms, during gym period. Screenings will include Massachusetts Mandated Vision screening, Hearing screening, Heights & Weights, and Postural Screening.

Legislative Mandate: MGL c71 s57 "…Upon entering kindergarten or within 30 days of the start of the school year, the parent or guardian of each child shall present to school health personnel certification that the child within the previous 12 months has passed a vision screening conducted by personnel approved by the department of public health and trained in vision screening techniques to be developed by the department of public health in consultation with the department of education… "…For children who fail to pass the vision screening and for children diagnosed with neurodevelopmental delay, proof of a comprehensive eye examination performed by a licensed optometrist or ophthalmologist chosen by the child's parent or guardian indicating any pertinent diagnosis, treatment, prognosis, recommendation and evidence of follow-up treatment, if necessary, shall be provided."

We would like to inform you of the policies that have been put in place to ensure the health and safety of children needing medication during the school day.

Our school district requires that the following forms must be on file in your child's health record before we begin to give any medicine at school:

1. Signed consent by the parent or guardian to give the medicine. Please complete the enclosed consent form and give it to your school nurse.
2. Signed medication order. The written medication order form should be taken to your child's licensed prescriber (your child's physician, nurse practitioner, etc.) for completion and returned to the school nurse. This order must be renewed as needed and at the beginning of each academic year.

Medicines should be delivered to the school in a pharmacy or manufacturer-labeled container by you or a responsible adult whom you designate. Please ask your pharmacy to provide separate bottles for school and home. No more than a thirty-day supply of the medicine should be delivered to the school. To ensure positive identification of your child, it is required that you provide the school nurse with a picture of your child which will be attached to the medication log.

When your child needs medication during the school day, please act quickly to follow these policies so we may begin to give the medication as soon as possible. Thank you for your cooperation in this matter.

Medication is not dispensed in school on half days. If you have any questions, please contact the School Nurse. Thank you.

If you have a child that will be taking medication in school, please print, and complete the following forms and return to the school nurse:

Medication parent permission | Medication physician letter

Medication change protocol | Medication policy | Medication count

• Important Information About Skin Infections!
• Guidelines for Sick Children
• Guidelines for Parents about Influenza
• Hand Washing
• Breakfast
• Snacks
• Let's Eat!
• Your Child Needs Daily Activity -- Make It Fun & Safe!
• Give Your Child Healthy Food Choices At Home

Asthma/Allergies

• Asthma & Allergy
• Food Allergy Network

Diabetes

• American Diabetes Association

Sickle Cell Disease

• Tips for Supporting Students with Sickle Cell Disease

Miscellaneous

• Caritas Good Samaritan
• WebMD
• Massachusetts Department of Public Health- School Health Services
• Centers for Disease Control
• Massachusetts Department of Education
• Kids Health
• Brockton Hospital
• Brockton Neighborhood Health Center
• Brockton Board of Health
• City of Brockton
• MA Interscholastic Athletic Association (MIAA)

1. The nurse provides services with respect for human dignity and uniqueness of the client unrestricted by consideration of social or economic status, personal attributes, or the nature of health problems.
2.The nurse safeguards the client's right to privacy by judiciously protecting information of a confidential nature.
3.The nurse acts to safeguard the client and the public when healthcare and safety are affected by the incompetent, unethical or illegal practice of any person.
4.The nurse assumes responsibility and accountability for individual nursing judgments and actions.
5.The nurse maintains competence in nursing.
6.The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities and delegating nursing activities to others.
7.The nurse participates in activities that contribute to the on-going development of the profession's body of knowledge.
8.The nurse participates in the profession's efforts to implement and improve standards of nursing.
9.The nurse participates in the profession's efforts to establish and maintain conditions of employment conductive to high quality nursing care.
10.The nurse participates in the profession's efforts to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing.
11.The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.

ESHS with Consultation Grant