Illustration of a document with a green checkmark

Student Health Forms

Illustration of a document with a green checkmarkSchool Health Services Medical Forms

Your student’s safety is our top priority. Our nurses are your family’s partners in promoting your child’s health. Please keep your forms updated annually.

Below are some common forms needed for:

  • entrance to our schools (and athletic programs)
  • administration of medicine at school
  • release of medical information between schools and health care professionals.

IMPORTANT: Notifying School of Chronic or New Health Conditions

Notifying School of Chronic or New Health Conditions

Please let school nurses know every year about chronic health conditions that may affect your child at school, either on the back-to-school forms, by calling 245-2631, or emailing the nurse’s office.

Even if you have let the school system know in previous years, please update your child’s information each year, since things can change.

Maintaining confidentiality is important to us and health information is only shared with school nurses and those faculty responsible for the student’s safety in class. If you are willing to allow school nurses to give and receive information directly from your health provider, please complete a Release of Medical Information Form.

If you have further questions, contact your school or the Director of Student Services and Achievement (see below).

Registration and Back-to-School Forms

It is important for school personnel to have a signed, updated registration card on file each year. Without an up-to-date back-to-school form, a student may be ineligible to purchase dance tickets or participate in field trips.

A signed registration form gives:

  • school personnel legal permission to take action on behalf of the student in cases of emergency, even before a parent can be reached
  • information about health conditions, insurance, and hospital of preference, to help the school make appropriate decisions regarding care
  • up-to-date parent phone numbers and emergency contacts so that the school can notify parents as soon as possible in case of emergency.

Finding registration and back-to-school forms:

  • information about registering new students can be found here
  • back-to-school forms can be accessed through your parent PowerSchool portal

Forms for Doctors’ Physicals

Forms for Doctors’ Physicals

Forms and Procedures for Administering Medicine at School

Forms and Procedures for Administering Medicine at School

Administration of medications, especially short term, should be done at home whenever possible. However, if a student is required to take prescription or nonprescription medication during the school day, the following guidelines must be met:

  • A written order from the physician, dentist, or practitioner is required, stating
    the student’s name ,the name of medication , the dosage, the time, the route
    (oral, injectable, inhaled, patch, etc.),and the duration of time that it is to be
    given (e.g., one week, the school year, etc.), along with the
    parent’s/guardian’s signature. Medication forms are available below or in your school’s clinic. Forms must be completed annually.
  • Prescription medication must be in a container that has been labeled by the pharmacy and has the most current prescription date. Over-the-counter medication must be
    in a sealed, unopened new bottle.
  • Parent /guardian must deliver medication to the school clinic, as students are
    not permitted to transport medication.
  • All medicine must be picked up by a parent at the end of the school year.
    Medicine that is not picked up will be disposed.

Release of Information Forms

Release of Information Forms

These forms allow release of confidential medical information on a student between the school and the student’s health care provider. It is required that the form be signed by the child’s parent or guardian before medical institutions can provide any information to the school nurse regarding the child’s health or any activity restrictions. Likewise the school nurse cannot contact a health care provider directly on behalf of a student without a signed release form.

Para leer este sitio web en español, indica “Translate” (traducir) en la parte por encima de la página y escoja Español.

To Learn More

Dr. Kendra King
Director of Student Services and Achievement
1562 Dairy Road
Charlottesville, VA 22903
(434) 245-2400
KingK1@charlottesvilleschools.org