Sharon Beckham and Gail Willie School Nurses 301-774-7455, ext. 141 or 120 cell: 301-370-5850 channel 5 of the 2 way radios sharon.beckham@ssfs.org

Medical Emergency Form
Medication Order Form
Physical Exam Form
Immunization Record Form (click ok if the dialogue box appears)
As Needed Medications for Dorm

2005-2006 Forms:
Medical Emergency Form 05-06
Physical Exam Form 05-06
Medication Order Form 05-06

NOTE: You will need Adobe Acrobat Reader to view and print these forms. Click here to download this free software if it is not already installed on your computer.

Dear Parents and Guardians,

Enclosed please find the medical forms for the 2004-2005 school year. The Medical Emergency Form must be filled out each year for all new and returning students. Please note that any medication, whether given at home or at school, must be listed on this form. If your child will be taking any over-the-counter medication not checked off on the Medical Emergency Form or any prescription medication at school, the Medication Order Form must be completed by a physician, nurse practitioner or dentist. A parent/guardian signature is also required on this form. This form is also required for any medication that will be administered on overnight field trips.

All new students, students entering 3rd, 6th and 9th grades, students with pre-existing health conditions, and Middle and Upper School students participating in interscholastic sports must have a current Physical Exam Form on file. In recent years, most Middle School students have chosen to participate on one or more interscholastic teams. Therefore, it is recommended that all Middle School students receive a physical exam prior to returning to school so that they are not excluded from a team that they may wish to join. Middle and Upper School students without up to date physicals on file will be excluded from all practices and games.

Maryland State law requires all students to be up to date with their immunizations. If immunizations are not up to date by September 27, 2004 the child will not be allowed to attend school. Please note the following:

• Students in PK-3rd grade are required to have 3 hepatitis B vaccines


• Students in PK-3rd grade are required to have one Varicella vaccine administered on or after the first birthday or proof of the disease in the form of a note from the physician or proof of immunity by positive blood test


• Students 5 years and older are required to have 2 measles vaccinations and one each of mumps and rubella (all must be administered on or after the first birthday)

All forms are due by July 15, 2004. If you have any questions or concerns, please contact the Health Center at 301-774-7455 ext. 141.