Medical Forms

Medical Forms

Student Health Examination Form - A physical examination dated the year of admission to Fontbonne Hall Academy is mandatory for all students. The form must be signed, dated and stamped by your healthcare provider.  Due to insurance constraints we will accept physicals signed within the prior 12 months but they must be followed up by a new physical examination at the end of the 12 month period. 

Immunizations - A copy of your daughter's immunization must be attached to the physical. If your daughter is entering the 12th grade she must fulfill the new Meningitis requirement which mandates that all students entering 12th grade must have a meningococcal vaccination on or after their 16th birthday, as well as two varicella immunizations.

Sports Participation - Any student participating in interscholastic sports at Fontbonne Hall Academy must have on file in the Nursing Office the following: an updated medical form with clearance and a concussion form.  All physicals for participation in school sports shall be valid for a period of 12 months through the last day of the month in which the physical was conducted.  A student athlete will not be allowed to participate or try out for any athletic team until all forms are reviewed and on file in the Nursing Office.  No exceptions will be made.

Prescription Medication Form - If your daughter has a history of asthma and/or severe allergies that require the use of an inhaler and/or an Epinephrine auto injector this form must be completed and renewed annually. This form allows your daughter to carry and self administer these very important medications in school.  It is essential that she carries these medications on her person especially during gym and or physical activities. An extra inhaler and or Epinephrine auto injector should be given to the school nurse and it will be kept in the Nursing Office.

Thank you for completing the below medical forms. If you have any questions or would like to discuss any medical conditions with me, I can be reached directly at (718) 748-2280. May your high school years be a time of growth and enrichment.

Christine Viehl, R.N. (School Nurse)

student health examination form

self-medication release form

prescription medications Form

personal health history form

concussion form

SAMPLE RECOMMENDED INTERVAL HEALTH HISTORY FOR ATHLETICS