Health Forms

Health Forms

Health Services would like to welcome you to Country Day. Below you will find the necessary medical forms needed for the upcoming school year.    

You will need to submit proof of required immunizations and a Physical Exam Form as soon as they are completed, as these are critical health forms. For lower and middle school students, all physical exams must be done by a doctor (licensed in the United States) on or after May 1.  All forms must be submitted by August 1. For all Upper School students, physical exams must be done by a doctor (licensed in the state of California) on or after May 1. The forms must be submitted by August 1 or by the start of first athletic practice before start of school. The forms should be sent to Jan Capon, RN, Health Services at 9490 Genesee Ave., La Jolla, CA 92037; Fax to 1-888-453-0072; or email to Nurse Jan Capon at  Please keep a copy of all forms for your own records. 

The information you submit will be maintained by the Health Services in the strictest confidence and will provide the basic data essential to your care. 

CLICK on the drop down sections below to print out the forms you need for your student.

Jan Capon, RN, BSN
School Nurse/Wellness Coordinator   
p  858.453.3440 x137  |  f   888.453.0072


A new law California (SB 277) was passed January 1, 2016 that states:
  • California schools can no longer permit immunization exemptions based on personal beliefs for children in childcare and public and private schools
  • Students transferring from a California school with Personal Belief Exemptions submitted before January 1, 2016 will remain valid until a pupil reaches kindergarten or 7th grade; 

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Physical Examinations

Physicals are required for all new students as well as those who will be entering Tiny Torreys, Jr. Kindergarten, Kindergarten, Grade 1, and Grades 7-12 (No physicals needed for Grades 2-6) prior to the start of the upcoming school year. The physical evaluations must be completed on or after May 1 and submitted by August 1.  If your child’s physician is unable to see your child in time to meet this timeline, we suggest you have the exam completed at a CVS Minute Clinic. They perform school/sports physicals for a nominal fee on a walk in basis.

  The physical exam needs to be performed by a physician licensed in the state of California and needs to be completed in its entirety and returned to health services by August 1.  If the student is participating in any fall sports, and practices begin prior to August 1 the physical must be completed and turned in prior to the start of sport practices. Students will not be allowed to participate in any sports until immunizations are up to date and the physical has been completed and turned in. 

FOR ALL STUDENTS: Students will not be allowed to attend the first day of classes until immunizations are up to date and the physical has been completed and turned in.

Health and Emergency Form

The health and emergency form is required for all students annually but it is part of the online registration in August prior to start of school. After registration is complete, please contact health services if you need to make changes to this form.  Form can be found below by entering grade level - click on expanding menu.

Medication Administration Release Forms

No students are allowed to carry medications of any kind without permission of the parent and school nurse.

Students taking prescription AND/OR over-the-counter medications during school hours will need to have a Prescription Medication Administration Release Form and/or an Over-the-Counter Medication Administration Release Form (for medications other than Acetaminophen, Ibuprofen, Tums and Sudafed) filled out in its entirety prior to the start of school each school year. No medication will be allowed or given at school until this form is submitted, even if the medication was given at school the previous year.  Forms can be found below by entering grade level - click on expanding menu.


Prescription Medication administered during school hours need to be in the original prescription container and in a Ziploc bag labeled with the child’s name, grade, parents' names, two emergency phone numbers and a current picture of the child. It is best to take the prescription medication form with you to your physical since the form must be signed by your physician. 


The health and emergency form parents complete online during registration in July 2016 covers the following over-the-counter medications. Parents will need to submit this form only once during the school year. 
    • Acetaminophen (Tylenol)
    • Ibuprofen (Motrin or Advil)
    • Sudafed
    • Benadryl
    • Tums
Other over-the-counter medication not listed above require a parent’s additional consent through the Medication Administration Release Form. Medications must be in the original container and in a bag properly labeled with the student’s name, grade, parents' names and phone numbers. 

It is to the discretion of the school nurse or designated health provider to administer any over the counter medications. It is best to give any medication at home prior to arrival at school. The first dose of any medication should never be given at school. ALL MEDICATIONS MUST BE PICKED UP BY THE END OF THE SCHOOL YEAR OR THEY WILL BE DISCARDED.