Health Forms

2022/2023 ANNUAL STUDENT HEALTH FORMS

Please submit the following annual health records and forms, as needed and indicated by your child’s age and specific health status, prior to your child’s first day of school. Please PRINT the forms from the indicated links, complete in full, and MAIL (or drop off) to St. Michael’s Country Day School, 180 Rhode Island Ave, Newport, RI, 02840, Attn: Hadley Bazarsky/ School Nurse. Thank you!

DO NOT EMAIL HEALTH RECORDS

• ALL families – To be completed by a parent or guardian, one for each student attending St. Michael’s: 2022/23 Annual Student Health History
• ALL families please submit the most recent copy of your child’s RI State Physical Exam form including complete immunization record (the doctor completes and signs this form following each annual exam). Print outs of online portal records are NOT acceptable. Forms are current for 1 calendar year.
• ALL families must sign a Consent For Emergency Treatment

• PRESCHOOL – 8th GRADE ONLY (This form does not apply for Toddlers): Consent For Standing Order Tylenol or Ibuprofen
• All KINDERGARTEN students are required to have a vision exam provided by either their pediatrician, an optometrist or an ophthalmologist, before the end of September 2021. There is a space on the RI physical Exam record for pediatricians to indicate the exam was completed (exams within one calendar year are current). IF this was not completed on your child’s record, or you have any concerns regarding your child’s vision, contact your physician or seek an appointment with an eye care professional.
• PRESCHOOL, PREKINDERGARTEN, OR KINDERGARTEN Physical Exam forms should include documentation of lead screening (bottom row of assessments on form).
• 6TH, 7TH, OR 8TH GRADE Physical Exam forms should include documentation of scoliosis assessment (bottom line of physical exam record) along with updated required immunizations for 7th and 8th graders (HPV). 7th graders also need a vision screening documented on their physical exam form by physician

• MEDICATION ORDERS – To be completed by a parent or guardian AND PHYSICIAN for any student who will need medication (prescription OR over-the-counter) at school and/or on a field trip. 2022/23 Medication Orders
• FOR A STUDENT WITH A DIAGNOSED SEVERE ALLERGY (required): Emergency Health Care Plans (EHCP) – to be completed by a physician and signed by parent/guardian (this link is an example form, a doctor’s specific EHCP orders are an acceptable alternative). If your child is in middle school, the doctor must indicate on the EHCP if the student is allowed to self-carry and self-administer their Epi pen.
• FOR A STUDENT DIAGNOSED WITH ASTHMA (required): Asthma Action Plan

Physicians must indicate if middle school students are allowed to self-carry and self-administer inhalers. To be signed by both physician and parent/guardian.

Please submit this signed form to your child’s previous school so that St. Michael’s Country Day School may receive your child’s official records. If you have any questions, please contact Sandy Merten, Director of Enrollment, at smerten@smcds.org.

School Nurse 401-849-5970 ext. 389

Last Revised 4/2022