School Health Forms

EMERGENCY MEDICAL/ ACTIVITY PARTICIPATION PERMIT  Should an emergency occur and medical attention is needed, this form provides written permission to treat your child and a means of contacting you.  It also provides written consent for your child to participate and attend field trips, games and other school-related activities.  This form must be signed each school year at enrollment.

HEALTH HISTORY  A health history provides the school nurse with pertinent information on allergies, medications, on-going illness or injuries, or situations that can affect the student’s daily school activities and learning process.  The history is updated at enrollment by the parent/guardian.  All information is confidential and shared only with USD 384 staff, teachers, coaches, etc. who may “need –to-know” for effectively assisting your child.

IMMUNIZATIONS  Immunizations are recommended for optimal health and are required by the State of Kansas in order to attend public schools. 
A complete list of the recommended schedule of each vaccination and dosage number can be found at the following website: http://www.kdheks.gov/immunize/index.html.
Dtap, Polio, MMR, Hepatitis B, Hepatitis A, Varicella (Chicken Pox), Hib, and PCV (Pneumonia) vaccinations are now required to enter Pre-School and/or Kindergarten. These requirements continue thru first grade. A Tdap booster is required at 7th grade if more than 2 years since the previous date.
A complete record of all immunizations is needed at Pre-School and Kindergarten enrollment. Thereafter, any new immunizations or updates received should be sent to the office to keep school records updated. This can be a written statement from the doctor, Emergency room record, or a copy of the pink colored "Kansas Immunizations Book."
Medical Exemption requires a written statement from a physician yearly.
Religious Exemption requires a written/signed statement from parents.

PHYSICAL EXAM FORM:  Kansas law requires a physical examination of all Kindergarten students and any new student entering the district, regardless of grade, including Pre-School students.  The exception is Kindergarten students who were Blue Valley Pre-School students the previous year.
If you currently do not have a regular family physician or pediatrician, an exam completed by an RN from a public health department is acceptable. Exams performed by chiropractors are not acceptable by the State of Kansas. A School Form is available.

For Students in grades 5-9 and those participating in High School Sports a yearly physical exam is required. The form is labeled as Pre-Participation Physical Evaluation (PPE) provided by the Kansas State High School Activities Association. The signatures of the physician, parents/guardian and the student are required. Copies of either physical form are available at the school offices or can be downloaded from this website.

REQUEST for ADMINISTRATION OF MEDICATION  The school is able to administer medications during school hours, field trips, etc. with this signed permission form on file and the medication supplied by parent/guardian.
Over-the-Counter Medications must have the completed form signed by a parent/guardian only. Medication should be sent in original container and labeled with the student's name and clear instructions.
Prescription Medications must have the completed form signed by the prescibing physician and parent/guardian. Medication should be sent in original container and labeled with the student's name and clear instructions. Pharmacies will supply extra labeled bottles for school use, if requested.
Any hand-written notes and/or medication sent in other containers, zippy bags, envelopes, etc. will not be accepted or administered.
All medications will be kept locked in the student's school's main office and dispensed by the school nurse or designated staff.

SELF MEDICATION PERMISSION  This form is similar to the Medication Permission form, but allows the student to administer the medication themselves. Medications allowed are: Inhalers, Epi-pens, and/or Insulin. All Sports Inhalers must have this permission form on file.  This permission does not include any controlled medications such as Ritalin, Concerta, etc. or any over-the-counter medications. A physician's signature is required along with the parent/guardian. It is highly recommended to keep an extra inhaler, epi-pen, or insulin at school in case of an emergency, lost or forgotten medication.