Holy Name of Jesus
School
Forms
 
 
Holy Name of Jesus Downloadable Forms
Confirmation Service Hours Form This form is necessary to record all service hours to satisfy eighth grade Confirmation requirements.
Take Your Child to Work Form - 2 part form Take Your Child to Work day form.  Please make sure these forms are filled out and submitted to the office before the scheduled day of absence.
  • Submit the Absence (top part) Form to the homeroom teacher at least one week prior to the date the child will be absent.
  • Submit the Return (bottom part) Form to the homeroom teacher the day following the absence.
Field Trip Permission Parental Permission and Waiver for Field Trip
Request for Child Care Provider - CD Transportation Dept
  • Use the Request for Child Care Provider form if your day care provider is changing and your require a new bus stop.  This form should be submitted to the school office. 
  • Also use this form every year to make sure your child(ren) have a day care provider bus stop for the FOLLOWING school year.  This form must be submitted to the school office by the end of the school year so that the Central Dauphin Transportation Dept. can provide a correct bus stop.
Parental Request and Physician's Order for Medication

 For students who require prescription medication during school hours.  Please get this form signed by your physician.  We can not administer any medication unless we have this form on file.  Please read this form carefully.

                                                                                     

Authorization for Non-Prescription Medication Form

For students who require the limited administration of non-prescription medication during school hours.  We can not administer any medication unless we have this form on file.  Please read it carefully.

                                                                                         form new 0809 school year

Vacation Form Please submit one form per child to the homeroom teacher at least 1 week prior to a Vacation or Trip.   
Dental Exam Form This form should be submitted to the school prior to a student entering kindergarten, third and seventh grade.  The form is given to new students entering these grades and at the end of the second and sixth grade school year. 
Department of Health Dental Exam Form Dental Exam Form
Central Dauphin Health Requirements Letter
 
Pennsylvania School Health Law requirements for children entering school.
Private Physician's Report of Physical Examination of a Pupil of School Age Form This form is required for all children entering kindergarten or HNJ school for the first time and also for sixth grade.

 

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Holy Name Of Jesus School
6190 Allentown Boulevard Harrisburg, PA 17112-2603
Office (717) 657-1704 Fax (717) 657-9135

 

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