Forms

Health Forms

Student Health Forms

For students new to Providence Academy, the following health forms are required prior to starting the school year.

Pre-K
Health Care Summary Form (physician signature required)
Student Information Card
Emergency Contact Form
Student Immunization Form Pre-K
Immunization Requirements

Kindergarten through 12
PA Health Information Form
Emergency Contact Form
Student Immunization Form K-12
Immunization Requirements

Medication At School

All medication must be kept in the health office during the school day. Students need a signed medication authorization form to receive medication from the health office. These forms are submitted yearly. Acetaminophen and ibuprofen may be given to students in grades 6-12 with a parent signature. All other medications, prescription or over-the-counter, require physician and parent signature. EpiPens and albuterol inhalers may be self carried when a medication authorization is on file. Albuterol inhalers for students in Lower School are kept in the health office.

Authorization for Administration of Medication
Authorization for MS-US OTC Medication

Asthma

Please submit an updated copy of your child’s Asthma Action Plan and the Asthma Individual Health Plan each year. Students in grades 6-12 who self carry their albuterol will need to complete the Student Inhaler Agreement. If your physician has not provided you with an Asthma Action Plan and your child may need albuterol or other medication for their asthma, please complete the medication authorization form.

Asthma Individual Health Plan
Inhaler Student Agreement
Authorization for Administration of Medication

Food Allergies

Please submit an updated copy of your child’s Anaphylaxis Action Plan and Allergic Reaction Questionnaire each year.  If your physician’s office has their own version of the Anaphylaxis Action Plan, that is acceptable.

Allergic Reaction Questionnaire
Anaphylaxis Action Plan

Seizures

Please submit an updated copy of your child’s Seizure Action Plan and Parent Questionnaire each year.

Seizure Action Plan
Questionnaire for Parent of a Student with Seizures

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