Physical Form

Physical Form

Dear Parents/Guardians of 9 & 11 Graders:
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 Office.

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.

             The date 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

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