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Medical Forms | School Nurse

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Northwest Region 7 School District Health Services

Dorothy Mitchell, RN  
Amanda D'Urso, RN

Phone: 860.379.8525, ext. 2618 or   ext. 2619
FAX : 860.379.8940


Updated respiratory virus guidance from the CDC :

District Enrollment Requirements:    Health Office

In accordance with BOE policy students entering school must present at the time of registration proof of age, evidence of legal residence and must meet the State requirements for immunization & health assessment.

At the time of registration parent/guardian must present proof of adequate immunization.   If the child is exempt from immunizations due to a medical reason, the parent/guardian must provide a notarized State of CT  Exemption form.

Students enrolling in grade 6 or 10, or those students enrolling from out of state must have a current health assessment (State of Ct Health Assessment Record) on file.  10th  graders must present the form before the end of their 10 grade year. 

Parent/ guardian must complete the Pink Student Health Emergency Information Form. 

If the student has any medical concerns the parent/guardian should  speak with the Health Office staff to ensure proper planning has occurred prior to their start of school

First page of the PDF file: CTWIzInfographic

Students must register for sports tryouts using Family ID/Arbiter Sports.

Anyone who is not registered by these dates is not guaranteed the required approval to participate in tryouts. Once registration has been entered into Family ID, the nurses then begin the approval process by certifying that the following are on file in the Nurses Office:

Sports registrants must have:

  1.  A physical that is less than 13 months old on file in the Nurses Office
  2.  No current physician-imposed restrictions from previous injuries or conditions
  3.  Those with history of concussion must have on file in the Nurses Office a physician note clearing the concussion, and  have completed the return to play protocol. 

You may use Family ID/Arbiter Sports at any time to check for when your physical expires.  You will also get an email from Family ID site 60 days in advance of the expiration date of your physical. 


Emergency Health Form 2024-2025 (PDF)

To be completed every year and/or when details change

CT  Health  Assessment  Record (PDF)

Used for  mandatory physicals in 6th, and 10th grades as well as new enrollments to the district.  This form  must be on file in the health office and updated every 13 months for sports participation. 

Medication Authorization Form 2024-2025 (PDF)

Every student who requires any medication in school, on field trips or athletic events must have this form completed by MD every year.  Students may carry their own Epi pens, inhalers and diabetes supplies BUT there must be a signed MD order on file in health office for the medications.

Standing Order for Ibuprofen, Tylenol, Tums Parent Permission Form 2024-2025 (PDF)

This form allows the nurse to administer Tylenol, Ibuprofen and TUMS  with the parent /guardian signature.  All other medications must have written medical authorization from the physician.

Asthma Action Plan and Medication Authorization pdf.pdf

For students with asthma and inhaler usage

 Emergency Allergy Medication  Authorization . pdf

To be completed by the physician each year.

Medical Exemption from Immunization (PDF)

For students who are not immunized due to medical reasons.

Husky Insurance . pdf

Explanation of insurance access for those without insurance