Application '17-'18

Re-registration

Release of Records

Health Forms

The Nurse’s Office requires a copy of an inquiring student’s current immunizations, current physical and a copy of our Confidential Health History Form to determine if the student will need any updated immunizations and if there are any health problems the student might have.
The Parent/Guardian will be notified if there are any immunizations missing or need updating, which can be done at the same time the student has her School Physical Examination completed (State of Connecticut Health Assessment Record Form HAR-3).

Please use this document as an added guided to completing the medical paperwork: Medical Procedures Guide. 

The following forms require both Parent/Guardian and Physician’s signature. Please complete the following forms after July 15th and send to Health Office.

  • These forms should be taken with the student when she goes to have her school Physical Examination.
    School Physical: (State of Connecticut Health Assessment Record Form (HAR-3).
    a. Part I – To be completed, dated and signed by Parent/Guardian.
    b. Part II – Medical Evaluation – To be completed, dated and signed by Physician. (Be sure date of Exam is written in at top of page).
    c. Part III – Immunization Record. To be completed, dated and signed by Physician. OR the physician should attach a complete list and dates of the student’s immunizations.
  • Tuberculosis (TB) Risk Assessment; including a List of High Incident Tuberculosis Countries. To be completed at the same time when the school physical examination is preformed; To be completed, dated and signed by Physician.
  • Over-the-Counter Authorization Form. This form allows us to give your student over-the-counter medications if she should need it (headaches, cramps, fever, toothache etc); To be completed, dated and signed by Parent/Guardian and Physician.
  • Prescription Medication Authorization. For any student requiring to take Prescription Medication while at school. It is necessary that a separate form for each medication is used or when there is a change of dosage. To be completed, dated and signed by Physician.
  • CIAC Pre-participation Physical Evaluation (Connecticut Interscholastic Athletic Conference) 
    a. History Form – To be completed, dated and signed by Parent/Guardian.
    b. Physical Examination Form – To be completed, dated and signed by Physician.

 

For students with either a Religious or Medical Exemption for Immunizations

  • State of Connecticut Department of Public Health: Immunization RELIGIOUS Exemption Statement – 2 pages. MUST be signed by either a Judge or Family Support Magistrate; Clerk/Deputy Clear; Town Clerk; Notary Public; Justice of Peace; an Attorney licensed to practice in the State of Connecticut; Commissioner of the Superior Court; School Nurse.
  • State of Connecticut Department of Public Health MEDICAL Exemption Certification Statement – 1 page

For more information regarding the application process please contact:

Sister Kateri, SCMC Director of Admissions

Academy of the Holy Family 54 West Main St. Baltic, CT 06330

phone: 1-860-822-6279  email: admissions@ahfbaltic.org

Skype: admissionsahfbaltic

Students