Dear Parents, As we prepare for the upcoming school year, it is time to begin preparing mandatory health forms for the upcoming school year. Our procedures closely align with other private schools in the Atlanta area. Cornerstone Christian Academy requires an annual physical for every student in order to begin the school year. Guidelines require that the physical exams must take place between April 1 and July 31. We suggest using your family well-care provider for the annual exam. If you are unable to secure an appointment during the required time period, we have secured a flat rate fee at the following clinic: Piedmont Urgent Care By WellStreet - flat rate fee of $25 (2 locations-no appointment needed during their working hours) 2700 Clairmont Road/Atlanta, GA 30329 The Physical Exam Form must be submitted to the Registrar s office prior to the start of school in order for your child to attend classes. You child will not be allowed to begin the school year with missing or incomplete forms. This is being done for the protection and well-being of our students and to ensure proper fitness for participation in school related activities. The Physical Exam Form can be downloaded from the Cornerstone Christian Academy website. Simply click the green down arrow at the top of our website to be directed to Medical Forms. Next click on the link Medical Forms Packet (.pdf). If needed, Allergy, Medical Care Plan and Authorization to Administer Medication Forms are available. Immunization Requirements as Mandated by the Georgia Department of Public Health In order to attend Cornerstone Christian Academy, all students must have a current Georgia Certificate of Immunization Record (Georgia Form #3231) on file by the first day of school in order to attend. Cornerstone s guidelines are outlined below: Current Students (Reenrollees) ALL current students matriculating to 1 st through 6 th grade and those moving to 8 th grade who have a current Form #3231 on file with the school do NOT need to submit a new form. ALL students in 7 th Grade must submit an updated Form #3231 that is Complete for 7 th Grade or higher. Before starting the school year, students need proof of an adolescent pertussis booster vaccination and an adolescent meningococcal vaccination.
New Students ALL new students in Kindergarten through 8 th must have a complete Georgia Form #3231 on file prior to the start of school. All completed forms can be dropped off at Cornerstone or mailed to the attention of Kim Ragland-Registrar, Cornerstone Christian Academy, 5295 Triangle Parkway, Norcross, GA 30092. If you prefer to email completed forms, please send them to Kragland@cornerstonecougars.net. If you have further questions, feel free to contact Kim Ragland. Medical Form Checklist Returning students in grades 1 through 6 and 8 th (Do NOT send in a new immunization form (3231) unless specifically requested by the Registrar) Physical Exam Form: completed by physician or medical care provider (if special medical conditions exist: Allergy or Medical Care Plan Forms) ALL rising 7th grade students Physical Exam Form: completed by physician or medical care provider Immunization Form (Form 3231): Complete For 7 th Grade of Higher (if special medical conditions exist: Allergy or Medical Care Plan Forms) New students K-8 and ALL rising 7th grade students Physical Exam Form: completed by physician or medical care provider Immunization Form (Form 3231): Complete for school attendance (if special medical conditions exist: Allergy or Medical Care Plan Forms) Sincerely, Kim Ragland - Registrar Melissa Dill - Lower School Principal Theresa Tamel - Middle School Principal
PHYSICAL EXAM FORM The physical exam must be completed by a physician. STUDENT NAME: of Birth: Age: M/F Entering Grade in August 20 VITAL SIGNS Height Weight B/P (resting) Resting Pulse Pulse (post exercise) Pulse (after brief rest) PHYSICAL EXAMINATION Head/Neck Lungs Abdomen/Hernia Spine Extremities Cardiac Other Findings: The student was found to be free of communicable diseases. Yes No The student was checked for scoliosis, scapula prominence and shoulder tilt. Yes No The student s vision and hearing are normal. Yes No Student s General Condition: (please check one): Excellent Good Fair Poor Student is cleared for full participation in physical education and all athletics. Student is cleared after completing evaluation/rehabilitation for: Student is not cleared. Explain limitations/exemptions: Physician s Signature Physician s Stamp:
ALLERGY CARE PLAN FOR ALL ALLERGIES STUDENT NAME: M/F of Birth: GRADE: A. TO BE COMPLETED BY PARENT/GUARDIAN I hereby request that Cornerstone Christian Academy, through its designated authority, supervise and or assist in the administering of medication to my child,, according to the instructions contained on my physician's statement below. I release the Board of Trustees, the school, and any employee from liability for administering any authorized medication. Parent or Legal Guardian s Signature B. TO BE COMPLETED BY PHYSICIAN ONLY Allergy to: Life-Threatening? Yes No Has student been tested using "controlled/monitored"' allergy testing? Yes No Last Allergic Reaction: How was reaction treated? Has student been diagnosed with Asthma/Reactive Airway Disease? Yes No TREATMENT: Symptoms: Give Checked Medication ** **(To be determined by physician authorizing treatment) If a food allergen has been ingested, but no symptoms: Epinephrine Antihistamine Mouth itching, tingling, or swelling of lips, tongue, mouth Epinephrine Antihistamine Skin hives, itchy rash, swelling of the face or extremities Epinephrine Antihistamine Gut nausea, abdominal cramps, vomiting, diarrhea Epinephrine Antihistamine Throat tightening of throat, hoarseness, hacking cough Epinephrine Antihistamine Lung shortness of breath, repetitive coughing, wheezing Epinephrine Antihistamine Heart weak or thready pulse, low blood pressure, fainting, pale, blueness Epinephrine Antihistamine Other Epinephrine Antihistamine If reaction is progressing (several of the above areas affected), give: Epinephrine Antihistamine Potentially life-threatening. The severity of symptoms can quickly change Dosage Epinephrine: inject intramuscularly (circle one): EpiPen 0.3mg EpiPen Jr. O.15mg Twinject 0.3 mg Twinject 0.15 mg Antihistamine: give (medication/dose/route) Other (medication/dose/route) LS Students: Parents should supply EpiPen to the classroom teacher. If desired, an extra EpiPen could be provided for the main office. MS Students: EpiPen is required on campus within prompt access to student. (Note: Parents are also encouraged to supply an extra EpiPen to the Homeroom teacher.) Where on campus will the student keep an EpiPen (purse, gymbag, backpack, etc.)? Is student knowledgeable and able to self-administer EpiPen? Yes No Physician s Signature
MEDICAL CARE PLAN Please complete for medical conditions such as: asthma, seizure disorders, diabetes or other ongoing medical conditions that warrant a care plan. STUDENT NAME: M/F of Birth: GRADE: A. TO BE COMPLETED BY PARENT/GUARDIAN I hereby request that Cornerstone Christian Academy, through its designated authority, supervise and/or assist in the administering of medication and care to my child,, according to the instructions contained on my physician s statement below. I release the Board of Trustees, the school, and any employee, or agent, from liability for administering any authorized medication or care and do not hold them responsible for any medical care outside of what is specifically included in this Medical Care Plan. Parent or Legal Guardian s Signature B. TO BE COMPLETED BY PHYSICIAN ONLY MEDICAL DIAGNOSIS/CONDITION: Symptoms/Triggers: EMERGENCY ACTION STEPS TO BE TAKEN: 1. 2. 3. 4. 5. 6. 7. MEDICATION ADMINISTRATION INSTRUCTIONS: Medication Dosage Time to be administered Physician s Signature
AUTHORIZATION TO ADMINISTER MEDICATION Please complete for medical conditions such as: asthma, seizure disorders, diabetes or other ongoing medical conditions that warrant a care plan. STUDENT NAME: M/F of Birth: GRADE: PARENT/GUARDIAN STATEMENT I hereby request that Cornerstone Christian Academy, through its designated authority, supervise and or assist in the administering of medication to my child,, according to the instructions below. I release the Board, the school, and any school employee from liability for administering any authorized medication. I have read and understand the Medication Guidelines. Reason medication is needed*: Name of medication: Exact Dosage: Time(s) to be administered during the school day: Medication to be given for: (check one) Entire school year Until finished as ordered above Other: please explain below Other Instructions: * If medication is for anaphylaxis or asthma, this form is not required, if the Allergy Care Plan or Medical Care Plan has been completed. For office use only form received medication received Parent or Legal Guardian s Signature
MEDICATION GUIDLINES Students are not permitted to have medications in their possession on campus. If a medication needs to be taken during the course of the school day, the student must come to the front office to obtain it from the office staff. Records will be kept of all medications administered. Medications must be brought to the office to be logged in by the office staff. With certain medical conditions, such as diabetes, asthma, or severe allergies, the student may be allowed to carry the necessary medications or supplies. Students (grades 5th - 8th) who use an inhaler or carry an EpiPen, MUST provide an extra inhaler/epipen to the office staff prior to the first day of school. To safely administer medications during school hours, the following is required. MEDICATIONS All medicine must be in the original container. An Authorization to Administer Medication form must be used. The office administrator will not administer medications that are in plastic bags or other containers. The request must include: 1. Student s Name and Grade 2. Name of Medication 3. Amount to be given (exact dosage of medication) 4. Time(s) to be given 5. Reason for Medication to be given 6. Length of Time Medication is to be given. *Please Note: The dosage and instructions on the Medication Authorization Form MUST match the information on the prescription container - When filling a prescription, ask the pharmacy for a school bottle, and they will provide an empty container with the correct label. Please do this for all medications that are taken at school. The office administrator will not administer medications that are in plastic bags or other containers. All medications must be picked up from the office by the last full day of school in May. All medication that is not picked up will be discarded in June.