NYSSSA Student Health Assessment Form

Checklist

Dear Parents/Guardians:

When completing the Student Health Assessment Form, please make sure that the following items are carefully reviewed and completed by you and your child’s physician. Incomplete Health Assessment Forms will be returned to you and may jeopardize participation in the program.

1) Part 1, Questions 18 – 24 - We must have the insurance information for your child.

2) Part 1: Emergency Treatment Notarization - Please print your name (line 1), your child’s name (line 2), and sign at the bottom of the box (line 3). Your signature must be witnessed by a Notary of Public. (Your local bank will have a notary who can witness your signature for you.)

3) Part 2, Questions 33 and 34 -All medical conditions and medications currently being taken by your child must be legibly printed.

4) Part 2, Question 45: Meningitis Immunization - If you are waiving the immunization for your child, please sign your name on the line provided. If your child has already been immunized, please include the date on the line provided.

5) Part 2, Question 47: TB Screening - Your child’s doctor must complete this portion. If your child’s doctor can check “No” to A and B, no further evaluation is needed. If not, C and/or D must be completed and require a TB test within 6 months of the start of the program.

6) Part 2, Physician’s Signature - please make sure your child’s doctor signs the bottom of the health form to verify that he/she has reviewed it.