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© 2016 by Mercer Island Pediatrics.

By School District

WA State Forms

State Immunization Forms
Diabetic Students

If your child is coming in for a clearance physical exam, the history portion of the form needs to be completed by the student and parent prior to the appointment.

Doctors cannot provide a signature of clearance without this information.

Don't see your form?

Let us know so we can include it!

WA State Forms

WA State DOH Immunization (Status, Exemption, etc.) forms

WA State DOH Certificate of Immunization Status

WA State HCP Orders for Diabetic Students

WA State Immunization Requirements, pre-school

WA State Immunization Requirements, K-12

 

 

Auburn School District

MS Athletic Participation Medical Exam Form

HS Athletic Eligibility Packet - Exam Form on last 2 pages

Medication-at-School Authorization form

Bellevue School District

HS Athletes Medical History and Physical Exam form

Medication Authorization form

Individual Health Plan (standard) form

Individual Health Plan (severe allergy) form

Individual Health Plan (seizure disorder) form

Individual Health Plan (Type I diabetic) form

Individual Health Plan (Type I diabetic with pump) form

Highline School District

Athletic Participation Physical Exam form

Athletic Return-To-Play form

Athletic Return-To-Play (concussion specific) form

Medication Authorization form

Camp Waskowitz Medication form

Individual Health Plan (diabetes) form

504 Plan Health Concern Verification form

 

Issaquah School District

MS Athletic Participation Physical Exam form

HS Athletic Participation Physical Exam form

Summer Activity and/or Camp Physical Exam form

Elementary & MS Medication Authorization form

HS Medication Authorization form

Allergy Action Plan

Medication Authorization >72 hrs (disaster planning) form

Physician's Orders for Special Nursing Care

 

 

Lake Washington School District

MS: Athletic Physical Exam Clearance form

HS Athletic Participation Medical History Form AND Physical Exam Form (both required)

Individual Health Plan (severe allergy) form

Individual Health Plan (asthma) form

Individual Health Plan (seizure) form

Health Care Provider Orders for Epinephrine Administration form

Medication Authorization form

Tdap Form for Middle School Students

Mercer Island School District

MS Athletic Participation Physical Exam form

HS Athletic Registration Packet - physical exam form on pages 3-4

HS Injury Return-To-Play Clearance form

HS Return-To-Play (concussion specific) form

Medication Authorization form

Asthma Health Care Plan form

Life-Threatening Allergy Health Care Plan form

 

Northshore School District

Athletic Participation History and Physical Exam form

Medication Authorization form

504 Plan Eligibility Physician's Exam form

 

 

Renton School District

Medication Authorization (asthma) form

Individual Health Plan and Medication Authorization form (allergy)

Medication Authorization form

HS Athletic Participation Physical Exam form

Seattle School District

Athletics Registration & Physical Exam form

Medication Authorization form

Diet Prescription For Meals At School form

 

Shoreline School District

Athletic Participation Physical Exam form

Snoqualmie School District

Medication Authorization form

Diabetic Physician's Orders form

Insulin Pump Diabetic Physician's Orders form

Chief Kanim MS Athletic Participation Physical Exam form

Mount Si HS Athletic Participation Physical Exam form