Health Forms

Health Forms

The following health forms are for general use and are only as needed or requested. All required forms are provided at registration.

Electronic Immunization Form
Formulario Para Dar Permiso De Administrar Medicamentos
Health History and Physical Assessment Questionaire (Kdg/new to district K-5)
Health Questionaire (yearly update grades 1-12)
Medication Permission Form
Release of Confidential Information
Secondary, Long Health Questionaire (new to district grades 6-12)

School Physicals

School health services are meant to augment, not replace annual health care supervision by your child's primary health care provider. Therefore, the district requests that students entering kindergarten, fourth, seventh, and tenth grades have a physical examination. The examination should be performed by the student's family physician and at no cost to the school district. A special form is available from your school, the Administration Building, at most local doctors' offices, or you can get the school physical form below.

School Physical Form

Health Care Plans and Related Forms

The following health forms are to be used only as needed or requested.

A health plan is a plan developed by the school nurse with the assistance of the parent for the management of a student's health concern at school. The following plans are available as fill-in-the-blank forms and can be filled in by the parent, signed, and returned to the school health office for use. The school nurse will contact you if further information or clarification is needed. Other health conditions also have plans but must be written on an individual basis. Please contact the school nurse. Some medications can be carried by and self-administered by students who are able to manage their condition and medications independently. Contracts are available below if this is an option.

Allergy-Anaphylaxis Plan Form
Allergy Informational Letter Primary Grades
Carta Informativa de Alergias para Grados Primarios
Allergy Informational Letter Secondary Grades
Carta Informativa de Alergias para Grados Secundarios
Allergy-EPI-Pen Contract
Contrato Para Estudiantes Que Traen Inyecciones de Epinefrina (EPI-Pen) A La Escuela
Asthma Informational Letter Primary Grades
Carta Informativa de Asma para Grados Primarios
Asthma Informational Letter Secondary Grades
Carta Informativa de Asma para Grados Secundarios
Asthma Emergency Plan
Health Questionaire for a Student with Asthma or Breathing Problems
Plan de Cuidado Para Un Estudiante Con Asma O Problemas Respiratorios
Asthma Contract
Diabetes Contract (Secondary Grades)
Contrato de Diabetes
Diabetes Provider Orders
Seizure Disorder Plan
Student Emergency Plan


Please be aware of changes to the immunization requirements for the 2016-2017 school year. If your student previously had a signed personal or religious exemption on file for one or more required immunizations, a new signed exemption is now required. Beginning 7/1/2016, parents deciding to take a personal or religious exemption for any state-required immunizations must provide to the school health office a new, signed exemption form EVERY year in order to meet school attendance requirements. For the new exemption form go to:, the health office, or the TSD district web site health services department > immunizations > exemption form.

If your student has received any new immunizations, remember to provide an updated immunization record to the health office as soon as possible, if you have not already done this. The district deadline is November 16th, 2016; students without all required shots or signed exemptions will be excluded from school attendance starting on that day. If you have questions about your child's immunizations, please contact your school health office. If you have questions about the State immunization procedure or requirements please contact the Larimer County Health Department Immunization Nurse, Jan Tarr, at 970-498-6799. Thank you.