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Departments » Health Services & School Nurse
HEALTH SERVICES & SCHOOL NURSE School Nurse - Sandra Hathaway, RN 315-852-3400, menu option 2 Click here for link to Family Health Network website
 Authorization for Medication Administration Form
(pdf file - 13 KB)
Self-Carry/Self-Administer Medication Form
(pdf file - 11 KB)
 Health Appraisal Form
(tif file - 1796 KB)
Physical form to be completed by the student's physician. Documentation of a current physical is required by NYSED for all new entrants, and in grades UPK, K, 2, 4, 7 and 10, and for any student wishing to participate in sports.
Interval Health History Form page 1
(tif file - 536 KB)
Screeing tool form, needs to be completed by parent/guardian along with page 2 prior to each sport season, if a health appraisal has not been done in the last 30 days.
Interval Health History Form page 2
(tif file - 494 KB)
Screeing tool form, needs to be completed by parent/guardian along with page 1 prior to each sport season, if a health appraisal has not been done in the last 30 days.
Pre-participation Form, page 1
(tif file - 2798 KB)
Sports physical form, needs to be completed along with page 2 by parent/guardian, student and physician, with a physical form to certify a student-athlete may participate in activities/sports.
Pre-participation Form, page 2
(tif file - 866 KB)
Sports physical form, needs to be completed along with page 1, by parent/guardian, student and physician, with a physical form to certify a student-athlete may participate in activities/sports.
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DeRuyter CSD
711 Railroad Street
DeRuyter, NY 13052
(315) 852-3400
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