Health Form Requirements 2010-2011

Community School Naples and the Florida Department of Health require these documents.
They must be submitted to Community School of Naples, prior to August 15, 2010.

All students: 2010/2011 Community School of Naples Emergency Consent/ Health

Services Form, side 1 and 2.
Community School of Naples Emergency Consent/ Health Services Form, 2010/2011,
completed by parent or guardian and signed in the presence of a Notary Public.

Community School of Naples Emergency Consent/Health Services Form, 2010/2011, must

have orders for medications signed by a physician or health practitioner licensed to
practice in the State of Florida. All students must have a signed order to start school
whether or not you are planning to use medications during the school day. If you do not
want your child medicated by the Nurse at school please indicate this on the form. (You
must still have the order signed by the doctor.)

Health Insurance Card Photo Copy or policy information must be included on the
Emergency Form.

All new students as well as Pre-K, Kindergarten, and Seventh Graders must submit the
following forms:

Student Health Examination form (yellow 3040) supplied by your physician or health
care provider. The physical exam must be dated within one year of the first day of
school. A parent must complete and sign PART ONE of this form. Photo copies are
acceptable.

Certificate of Immunization Form (blue 680) supplied by your physician or health

care provider. This must show all current immunizations. The Florida Department of
Health requires a Varicella (Chickenpox) vaccination for all students; two Varicella
immunizations are required for students K through second grade in 2010/2011. The
seventh grade requirement changed last year and a Tdap vaccine is required instead of a
Td for the 2010/2011 year. Your physician must sign the form as complete for the school
year or provide an expiration date as to when the shots will be completed. A photocopy is
not acceptable.

Seventh grade students must have a current Tdap, within the last five years.
Students will not be allowed to attend class for the 2010/2011 academic year without
proof of proper immunizations.

Have a question? Call 239-597-7575, extension 191.