Health Forms

Please read the description of each health form carefully as each is designed for specific physical assessment requirements or medication administration needs.

Southington Public Schools Physical Requirements letter

Southington Public Schools Immunization Requirements


Mandated Physical Forms

Mandated school physical form to be completed within one year prior to the first day of school for entry into Kindergarten, Grade 7, and Grade 10:

Health Assessment Record Grades K-12 and Sports Physical Form("blue form")


Mandated school physical form to be completed within one year prior to the first day of school for entry into Preschool:

Early Childhood Health Assessment Record-Preschool (yellow form)


Mandated school sports physical and permission forms necessary to try out and participate in school sports grades 6 through 12:

CLICK HERE TO GO TO SOUTHINGTON PUBLIC SCHOOLS SPORTS FORMS


Medication Administration Forms


Contact the school nurse to discuss your child's medication needs during the school day.

The term "medication" refers to any category of prescription and nonprescription preparations.

  • No medication will be accepted in envelopes or baggies. Do not send any type of pills, liquids, creams or lotions to school with your child.
  • A maximum three month supply can be brought to the school nurse by a parent, guardian, or responsible adult.
  • All medications must be picked up within one week following termination of order or on the last day of school by parent, guardian or responsible adult.

Authorization of a Parent or Guardian for the Administration of Ibuprofen or Aspirin Substitute Containing Acetaminophen allows Ibuprofen to be administered to students 12 years of age and up and Aspirin Substitute Containing Acetaminophen to students of all ages.

Authorization of Parent/Guardian for the Administration of Ibuprofen or Aspirin Substitute Containing Acetaminophen


Epinephrine Auto-injector Self-Administration form for students who are able to self carry and self administer Epinephrine with MD, parent/guardian authorization and School Nurse review:

Epinephrine Auto-injector/Benadryl Administration Form


Metered Dose Inhaler (MDI) Self-Administration form for students who are able to self carry and self administer their prescribed inhaler MDI) medication with MD, parent/guardian, and school nurse authorization:

Inhaler (MDI) Form


Authorization for Medication by School Personnel form for all medication administration EXCEPT the following:

  • Epinephrine auto-injector administration
  • MDI Self-Administration
  • Ibuprofen ages 12 and up
  • Aspirin substitute containing acetaminophen

Authorization for Medication by School Personnel



Asthma Action Plan

Asthma Action Plan Ages 0 to 11

Asthma Action Plan Ages 12 and Older


Diabetes Management Plan

The Diabetes Management Plan and School Treatment Authorization form is to be completed annually for any student with diabetes at the opening of the school year.

Diabetes Management Plan and School Treatment Authorization

Please contact your school nurse if you have any questions regarding the appropriate form for your child's medication needs.

All students requiring medication in school will have a Medication Administration Plan implemented by the School Nurse. This is an example of the plan:

SPS Medication Administration Plan

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