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Health Related Forms

Posted On: Tuesday, October 28, 2025
By: [email protected] Patnode

Below, you will find several links to health related forms or information.

For questions specific to MS Health Information, please contact Kim Letourneau, our MS Nurse:  [email protected]

For questions specific to HS Health Information, please contact Katelyn Gonyo, our HS Nurse:  [email protected]

 

Health Exam Form  –  A current Physical must be on file with our school nurses for any student to participate in our Athletics Programs.

Student Health Insurance  –  The School District has made arrangements to offer Student Accident Insurance to students (K-12) voluntarily and on an individual basis.

Authorization for Administration of Medication and Self Carry  –  If your Athlete will need to carry medication and self carry items such as epi-pens, please complete the form below and return to the Health Office.

Concussion Fact Sheet for Parents  –  Please click the link below for a fact sheet all about signs and symptoms of a potential head injury.

Head Injury – NCCS Return to Play Policy –

The following protocol has been established in accordance with the Concussion Management and Awareness Act.  When an athlete shows any signs or symptoms of a concussion:

  1. The athlete will not be allowed to return to play in the current game or practice.
  2. The athlete should not be left alone, and regular monitoring for deterioration is essential over the initial few hours following injury.
  3. The athlete should be medically evaluated following the injury.
  4. Return to play must follow a medically supervised stepwise process.

 

The cornerstone of proper concussion management is rest until all symptoms resolve and then a graded program of exertion before return to play.  The program is broken down into six phases; each phase will occur on a separate day and may require several days depending on the athlete and their injury factors.  Any return of symptoms ends the activity and the athlete is rested until the next day when they resume their last successful step.  The six steps involve the following:

  • Phase 1: No activity, complete rest until symptom free for no less than 24 hours and physician orders received clearing student to return to school and gradual return to play.

 

  • Phase 2: The student must pass post Head Injury Nursing Assessment which includes light aerobic exercise.  No resistance training allowed at this time.  With successful completion of Nursing Assessment, walking is acceptable.

 

  • Phase 3:  Sport-specific exercise, such as skating in hockey and running in soccer, no contact.  Progressive addition of resistance training may begin.  (Movements that require sudden change in direction should be avoided.)

 

  • Phase 4:  Non-contact training drills, such as those performed in sport practice.  (Movements that require sudden change in direction allowed.)

 

  • Phase 5: Full contact training in practice setting, with ultimate and final clearance by the NCCS School Medical Director.

 

  • Phase 6: Competitive game play.

 

If any head injury symptoms recur, the student should drop back to the previous level and try to progress after 24 hours of rest without symptoms.  The student should also be monitored for recurrence of symptoms due to mental exertion such as reading, working on a computer or taking a test (it will be the student, parent and teacher responsibility to report to the school nurse any objective or subjective symptoms observed).

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