Nysed Health Certificate/appraisal Form - North Colonie Central School District
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1
2NORTH COLONIE CENTRAL SCHOOLS
91 FIDDLERS LANE
LATHAM, NEW YORK
12110
Dear Parents:
New York State Education Law requires that each student receive a physical exam when
entering a school district for the first time and again in grades K, 2, 4, 7, 10.
This law also
requests a comprehensive dental exam. While the physical examination can be administered
by the school physician, and we can offer you names of dentists in the community; we urge you
to use your family physician/dentist for this purpose during your child’s summer vacation. In this
manner, a pattern of consistent, optimum health care can be established.
If your child has recently seen your family physician/dentist and will be a beginning
Kindergartner, 2nd, 4th, 7th, or 10th grader in September, please ask the doctor to complete
the reverse side of this form as well as the dental form. Although the forms must be returned
by the end of September, an examination administered not more than twelve months prior to
commencement of the school year in which the examination is required, will be accepted. For
those beginning Kindergartners, 2nd, 4th, 7th and 10th graders who have not received
examinations from a private physician by September, a visit to our school physician will be
scheduled in the fall.
Again, please return this form to your school nurse by the end of September. You are
reminded of the following:
1.
To notify us if it is necessary for your child to be absent due to illness
Call the school the first day of absence.
2.
To keep us informed during the school year on items below (changes)
3.
When the annual school health appraisals are made, you will be notified if
any abnormalities are found.
Please feel free to call us or send a note if we may be of assistance to you at any time.
Sincerely yours,
Mr. David Semo
Director of Pupil Services
To be completed by Parent:
Name of Pupil_________________________________Grade__________Teacher_____________________
Mailing Address_________________________________________Telephone________________________
Parent/Guardian
(home) ________________ (work) ______________
Parent/Guardian
(home) ________________ (work) ______________
Names of person, other than parents, to be called in case of emergency if neither parent can be reached
1. Name___________________Address______________________Hm. Tel._________Wk. Tel.____________
2. Name___________________Address______________________Hm. Tel._________Wk. Tel_____________
Family Physician___________________________Address________________________Phone #___________
Family Dentist _____________________________Address________________________Phone #___________
Medical Problems___________________________________________________________________________
Parent’s Signature_______________________________
Date__________________
1/15 DJD/appDS
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