Clinic: Health Info & Forms
Clinic phone: 703-992-0064
Student Health Forms
Forms to be completed when a student enters St. Ambrose School
- Virginia School Entrance Health Form
- Virginia School Entrance Health Form Instructions
- Certificate of Religious Exemption (If the administration of immunizing agents conflicts with the student’s or parents’ religious tenets or practices. )
Form to be completed at the beginning of each school year
Form to be completed if a student is to be given any medication at school
- Medication letter
- Medication Authorization Form (Not for epinephrine injections or inhaler. See below if school staff need to be authorized to administer an inhaler or injectable epinephrine to your child.)
Forms to be completed as needed for students with asthma or allergies
- VA Asthma Action Plan (pdf) or VA Asthma Action Plan (fillable)
- Allergy Action Plan Treatment Form
- inhaler authorization form
- Epinephrine Administration form
Forms to be completed for students with diabetes
- Diabetes Medical Management Plan
- Quick Reference Emergency Plan (Part A of Diabetes Medical Management Plan)
Human Papilloma Virus (HPV) Vaccine – Information for parents of rising 6th Grade Girls
- Letter from Virginia Bishops re: HPV vaccine
- Virginia Department of Health Information Letter re: HPV Vaccine
Lions Club Sight and Hearing Testing
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Resources for parents:
FARE (Food Allergy Research and Education): education and support to parents who need help managing food allergy.
Head Lice information from National Pediculosis Association
Heads Up: Concussion in Youth Sports: The Centers for Disease Control and Prevention has important information for coaches and parents on preventing, recognizing, and responding to a concussion.
