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Cantiague Elementary School
George A. Jackson Elementary School
Jeffrey Ratner Robert Seaman Elementary School
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Jericho Union Free School District
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Health Office Forms
New Entrants
Click
here
for the New Entrant registration packet
Mandated NYS Physical Examination Form
NYS Education Law Article 19 requires students who are entering the school district for the first time to submit a current and complete physical exam performed within a year of the school year. Student’s medical
concerns, fragile medical conditions, or social– emotional issues may impact their ability to participate fully in school.
It is important to have this information prior to school entrance to help with the student’s condition that requires routine or emergent care by school personnel.
A health examination can only be performed by a NYS private health care provider, a licensed physician, physician assistant, or nurse practitioner. Each certificate or appraisal must be signed and stamped.
Student Health History Form
The health history for new entrants should be completed by the student’s parent or guardian. A comprehensive health history includes but is not limited to: Current status of the student’s health problems, serious or life-threatening conditions, allergies, chronic illness and medications, accident or injuries, and psychosocial factors that may affect the student’s school performance.
Dental Form
NYS recommends having information regarding the student’s oral health. The dental exam can only be performed by a NYS licensed dentist. The form must be signed and stamped.
Immunization Record
The immunization record is obtained form your health care provider
New York State Public Health Law, requires that a child not be permitted to attend school unless the parent provides the school with a certificate of immunization or proof from a physician, nurse practitioner or physician's assistant that the child is in the process of receiving the required immunizations. The exact date each immunization was given must be included in the record. Each record must be signed and stamped. The immunization record must be submitted within 14 days of the first day of school. For students entering school from another country this record must be received within 30 days of the first day of school.
Click
here
to view NYS mandated immunizations for school entry.
Please return or
E-mail
completed form to the school nurse.
Form Instructions for Printing