Health Room Services

Title Description
Central Dauphin Health Immunization Requirements Pennsylvania School Health Law requirements for children entering school.
Dental Exam This form should be submitted to the school prior to a student entering kindergarten.
Department of Health Dental Exam Form This form is required for new students and students entering the third and seventh grades. The Health Room staff will send this form home with students at the end of the second and sixth grade school years.
Health Room Services Students Requiring Medication Information and requirements for Holy Name of Jesus School Health Room staff to administer medications to a student during the school day.
HNJ Authorization for Nonprescription Meds For students who require the limited administration of non-prescription medication during school hours. Health Room staff are not permitted to administer any non-prescription medication unless this form is on file. Please read this form carefully.
Parent Request and Physician's Order for Medication For students who require prescription medication during school hours. This form needs to be signed by your physician. We are not permitted to administer any medication unless the Health Room has this form on file. Please read this form carefully.
Physical Exam This form is required for all children entering kindergarten, sixth grade, or Holy Name of Jesus School as a new student.

Other Forms

Title Description
Confirmation Service Hours This form is necessary to record all service hours to satisfy eighth grade Confirmation requirements. This form can be filled out within one year prior to Confirmation.
Educational/Vacation Form Submit one form per child to the homeroom teacher at least 1 week prior to a vacation or trip.
Field Trip Permission Form Parental Permission and Waiver for Field Trip
Request for Child Care Provider- Central Dauphin Transportation Department Use the Request for Child Care Provider form if your day care provider is changing and your require a new bus stop. Submit this form to the Holy Name of Jesus school office. It is also necessary to submit 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 CURRENT school year. The Central Dauphin Transportation Dept. will be unable to provide a correct day care bus stop without this form. Note: Day Care providers must reside within the Central Dauphin School District boundaries.
Take Your Child To Work Form Take Your Child to Work day form. Make sure this form is filled out and submitted to the office before the scheduled day of absence.

  Bussing Forms                         Print out forms and return to the school office.