Health Services Forms

Dental Consent Form (Permission Form for Dental Services at School) (PDF)

Health Assessment Record (PDF)

Medicine Administration Authorization (PDF)

School-Based Health Centers Registration Form (PDF)

Right to Refuse Epinephrine (Epi-pan) Treatment Form

Public Act No. 14-176 regarding administration of an epi-pen as first aid to a student experiencing an allergic reaction. If you do not want an epi-pen administered as first aid to your child, please complete this form (in above link) and submit it to your child’s school nurse. Call Deb Chameides, Health Services Coordinator, with any questions at #860-695-8760.

This post is also available in: Español