Below are the required health forms for the 2015-2016 academic year. These are the only forms that will be accepted, with one exception: the immunization record may be a copy of your son’s on-going records from his health care provider. We encourage you to review the enclosed 2015-2016 D.C. Immunization Requirements with your son’s health care provider to ensure compliance. Please note the requirement for the Human Papillomavirus vaccine (HPV) and Vaccination Opt Out form included here. The Opt-Out form for HPV immunization must be signed and returned with the other forms, if the HPV vaccination is declined.
The Asthma Action Plan and the Action Plan for Anaphylaxis are required if your son has either asthma or anaphylaxis due to any cause. The STA Prescription/Non-Prescription Medication Administration form is to be used for all other medications ordered by a health care provider to be administered at school.
Every student must have an annual physical. The health forms are effective for one year from the date of that physical. If the forms expire during the academic year, your son will need to have another physical and submit new forms. (The school offers a two-week grace period for having the exam and submitting the forms). Please renew the STA Permission for Emergency Medical Treatment form when you renew the D.C. Health Certificate.
If your son is new to the school this academic year and has had a recent physical exam, please have your health care provider fill out and sign the D.C. Universal Health Certificate, including sports clearance.
Dental exams are now required annually for all students.
To expedite the processing of forms, area physicians and dentists have asked that you complete all but the professional sections of the forms before submitting the forms to them. Please do so.
A current (within the last 12 months) D.C. Health Certificate, STA Emergency Medical Treatment form, and Oral Health Assessment must be on file at school at all times. For exams occurring during the academic year, the forms will be advanced to the rising grade of the student at the end of the academic year. No form will be required until the next annual exam is due. It is the parents’ responsibility to insure that all exams are current at all times.
We look forward to working with you to ensure the health and safety of your sons in the upcoming year, and thank you for filling out these forms completely and accurately.
Jerilyn Stone, R.N., B.A.
St. Albans School Nurse
Director of Finance and Business Operations
Below are electronic copies of Health Forms for the coming year. Using Adobe's free Acrobat Reader, one can read and print the forms listed below.
PERMISSION FOR EMERGENCY TREATMENT
Parent's/guardian's signature required for administration of over-the-counter medications by the school nurse.
Parent's/guardian's signature required for emergency medical treatment.
A physician's signature is required for the administration of over-the-counter medications by the school nurse, the resident faculty (for resident students only), the athletic trainers, STA/NCS Voyager staff, and non-medical school employees (Field trips only).
Permission for Emergency Medical Treatment Form
DISTRICT OF COLUMBIA IMMUNIZATION REQUIREMENTS SCHOOL YEAR 2015-2016
All students attending school in the District of Columbia must present proof of appropriately spaced immunization by the first day of school.
Immunization Requirements Flyer
DISTRICT OF COLUMBIA UNIVERSAL HEALTH CERTIFICATE
MEDICATION ADMINISTRATION RELEASE FORM
This form must be completed and signed by a parent/guardian and the prescribing physician if your son is to receive prescription or prescribed over-the-counter medication during the school day. Please make a copy of the medication administration form for each medication to be administered.
Medication Administration Form
ACTION PLAN FOR ANAPHYLAXIS
If your child has an allergy that may result in the need of an EpiPen, this form must be completed and signed by a parent/guardian and the prescribing physician.
Action Plan for Anaphylaxis
ASTHMA ACTION PLAN
If your child has asthma, this form must be completed and signed by a parent/guardian and the prescribing physician.
Asthma Action Plan
DISTRICT OF COLUMBIA ORAL HEALTH ASSESSMENT FORM
MEDICATION REQUIRED FOR OVERNIGHT FIELD TRIPS