Required Medical Forms

Every student attending Perpich Arts High School must have a few basic medical forms completed, signed and delivered to the student health office by August 1 of the year a student begins classes or immediately following a change in health status during the school year.

The following forms must be filled out annually or following a change in health status

Annual health information form
Authorization for over-the-counter medication administration
Authorization for administration of prescription medication when required by student condition

 

Questionnaire required of any student with one or more of the following conditions:

anaphylaxis (food allergy or bee sting allergy)
asthma (parent questionnaire, student questionnaireRequest for student self-carry and self-administration of medication)
diabetes [this form will be available for students with diabetes at orientation]
seizures/epilepsy

Immunization record

This form must be completed only once during a student’s enrollment and updated as needed:
Pupil immunization record

Restriction of physical activity

Due to various medical conditions or following an injury or surgery, a student may need to restrict certain physical activities. In those situations, Perpich will ask the parents/guardians to request the family’s health care provider to complete a medical activity guide for the school nurse, who will share it with appropriate school staff.

Authorization to administer specialized health services

For any health-related procedures that must be done by a licensed nurse and are not related to other authorizations provided on forms related to care for diabetes, asthma, etc., this form provides permission for the Perpich school nurse to provide needed care. These procedures include but are not limited to chest physiotherapy, tube feeding on a pump, nebulizer use, tracheotomy care and mobility issues requiring the use of braces and/or other assistance.