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The Staples High School community inspires learning, fosters integrity, and nurtures empathy.

Health Services Common Forms


We are pleased to provide you with links to frequently used health forms and a quick reference to common questions and health issues. You are encouraged to review the information and call your school nurse with any questions or concerns, or to share important health information regarding your child.

School nursing is a specialized practice of professional nursing that advances the well-being, academic success, and life-long achievement and health of students. To that end, school nurses facilitate positive student responses to normal development; promote health and safety, including a healthy environment; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self advocacy, and learning (NASN, 2010)

Student Medical Emergency Form

This form is required for all students each year.

Health Assessment Record/Physical Exam (pdf)

This form (also known as the "blue form") is required for:

  • New students (including all Pre-K and K students)
  • All 6th and 9th graders
  • Interscholastic sports (every year)

Health and Developmental Questionnaire (doc)

This form is required for all new students Pre-K through 8th grade.

Medication Authorization Form (doc)

This form is required for the administration and self-administration of medication in school.


Immunization Exemptions

Medical exemptions (doc) This form is required when a physician verifies that a student is exempted from immunization requirements for medical reasons.

Religious exemptions (doc) – This form is required when parents/guardians request that their child be exempted from immunization requirements based on religious beliefs.

Concussion Info and Physician Care Form (doc)

This form is to be filled out by the child's physician on return to school following an assessment for concussion.

Food Allergy Medication Authorization

This form is required for all students who have a medical order for Epinephrine (EpiPen) in school.


Physical Activity Restriction Form (pdf)

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