Right Click to download ALL health forms
For easy reference, the forms are numbered at the top right of each page. All students must have forms 1 and 2 as well as a copy of an updated immunization record on file. Forms 3 and/or 4 should be completed only if applicable to your child.
Form 1- This is required for every student attending BCD. Whether or not you wish to give permission for the administration of over-the-counter medications at school, this form must be returned signed by a physician AND signed by a parent/guardian. This form also serves as a review of allergies, vision correction, and any other health concern.
Form 2- This required form (or your physician’s own form) is current if the exam was done after September 1, 2011. A copy of an updated immunization record should also be attached.
Form 3- Prescription medication form: Submit this form only if your child requires prescription medication during school hours. This is required for any prescription including epi-pens, inhalers, and nebulizer treatments. It is also required for any non-prescription items such as homeopathic remedies or over-the-counter medications you wish to be given which are not listed on Form 1. Physician AND parent/guardian must sign.
Form 4- Asthma/Allergy Action Plan: Submit this form only if applicable to your child. Please complete both sides. Physician AND parent/guardian must sign.
A parent requesting a medical or religious exemption for immunization, should contact me before August 15, 2012. The BCD Immunization Waiver form must be completed and signed for each new school year. Health forms 1 and 2 will still be required.
Finally, I would like to remind you to please keep me updated throughout the school year with any changes in your child’s health. These may include injuries, surgery, illness, or any other concern that may impact his/her school day. My phone number is 637-0755 ext.31 and my email is malexander@berkshirecountryday.org.
You may contact me over the summer at (413) 499-1686 or by email.
Thank you in advance for helping to ensure the good health of our BCD community.
