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Upper Freehold Regional School District

27 High Street, Allentown, NJ, 08501, US


Form Section 1


Allentown High School Health Form

(This form can be completed online or printed and returned to the main office.)

Health OfficeDiana Ricciardi, R.N.Phone: 609-259-7292, x1425FAX: 609-223-4355

Does your child have a severe allergy (bee sting, food, medication, other)?
If Yes, what treatment is necessary?

If your child has any other health problem or physical limitation, please notify the school nurse.

Check consent for school nurse to administer medication during school day.  (The school nurse is authorized to decline to administer a medication if the situation warrants.)

Medication Consent: I authorize the school nurse to administer the following medication.

The State of New Jersey requires that we ask the following questions:

Do you have medical insurance?
Will you accept a contact from an authorized medical insurance provider?
I have read this form completely and hereby give permission for my child to have those medications to which I have consented on this form.

Regarding Student Drivers: In the event your child become ill, this serves as written permission to permit your child to sign out of school and drive home provided they are physically able. Parent/Guardian will also be called for verbal permission to release student.

Full Name
Sign Here
Full Date