Holy Name of Jesus
Catholic School
 
  
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  Downloadable Forms
 

 

 

Forms

Form Description

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Health Room Services -Students Requiring Medication

 
Parental 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.


Authorization for
Non-Prescription Medication Form

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.


Central Dauphin
Health Immunization Requirements

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, sixth grade, or Holy Name of Jesus School as a new student.


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.


Dental Exam Form

 This form should be submitted to the school prior to a student entering kindergarten. 


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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.  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.

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Field Trip Permission

 

Parental Permission and Waiver for Field Trip

 
Vacation Form

Submit one form per child to the homeroom teacher at least 1 week prior to a vacation or trip.


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.

 
Confirmation
Service
Hours Form

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.

 

 

 

 

 

 


 
 
 
  Holy Name Of Jesus School
6190 Allentown Boulevard
Harrisburg, PA 17112-2603
Office 717-657-1704    
Fax 717-657-9135
© Holy Name of Jesus Catholic Church, All Rights Reserved 2006 - Present