Dear Parents/Guardians of 9 & 11
New York State Education Law Section
904 requires that all 9th and 11th graders have an
updated physical. At the start of school
we will be scheduling physicals with the school provider. Your 9th/10th grader needs a
physical either with the school provider or your own provider. You must provide the health office with a
copy of a completed physical. Please use
the New York State Health Examination form enclosed. If we do not receive a copy of the physical,
the students will be scheduled for a physical with the school provider.
Please complete the form below
indicating your preference for physical location and returned to the Health
Thank you for your cooperation.
Name of Student: _____________________________________________________
I wish for my 9th/11th grader to
receive a physical with the school provider.
I have arranged an appointment for my 9th/11th
grader with our own provider.
of the examination is .
If this form is not returned, any required physical will
then be scheduled in the Health Office with the school provider.
Parent/Guardian Signature Date