Cary Academy Required Medical Forms Checklist

CARY ACADEMY REQUIRED MEDICAL FORMS CHECKLIST

Please fill out and return the following required medical forms for the category of student(s) that will be attending Cary Academy for the 2011-12 academic year. Downloadable copies and a more detailed description of each form are available at: .

If you have any questions, please contact me at .Thank you!

******Please make a copy of all submitted forms for your records.

A. NEW STUDENTS (Complete all forms and submit prior to first day of school)

□ Insurance/Liability Information is now completed online and part of the Online Family Information Form-you may start completing this form as of July 1, 2011). Cary Academy requires the Family Information/Insurance Form be submitted prior to the start of school/first day of fall sports practice.

□ Physical (completed and signed by physician, physician’s assistant, or nurse practitioner in past year)

□ Student History and Health Assessment Form (completed by parent/guardian)

□ Immunization Form (completed and signed by physician-required by school within 30 calendar days from first day of school to comply with state law)

□ Medication Administration Form (completed, signed and dated by both physician/designee and parent/guardian for any medication given by staff or self)

B. RETURNING STUDENTS

□ Student History and Health Assessment Form-completed by parent/guardian if any changes in past school year (health concerns, medications, physician, dentist)

□ Immunization Form (signed by physician listing any new vaccines in past year)

□ Medication Administration Form (completed, signed and dated by both physician/designee and parent/guardian for any medication given by staff or self)

***Physical required annually for all athletes and for new student.

C. STUDENT-ATHLETES (INCLUDES NEW & RETURNING STUDENTS)

□ Physical (annual-completed and signed by physician, physician’s assistant, or nurse practitioner). Submit to School Nurse.

**** Submit any other forms pertinent to your student

FORMS FOR SPECIFIC MEDICAL CONCERNS (only complete if student has concerns listed in an area below)

□ Medical Clearance for Return to Physical Activity (completed and signed by attending

Physician). Form for student who has had recent injury, medical concern limiting physical activity.

□ Asthma Action Plan (completed by parent/guardian)

□ Severe Allergy Action Plan (completed by parent/guardian)

□ Diabetic Action Plan (completed by parent/guardian)

□ Specialized Health Care Form for Parents

□ Specialized Health Care Form for Physicians

FORMS FOR SPECIAL REQUESTS (submit only when needed)

□ Release of Medical Information Form