2025/26 After School Medical Forms

Medical Forms MUST be submitted in addition to online registration.
Children will not be able to attend the program until all documents are submitted.

• CT Early Childhood Health Assessment Record: https://portal.ct.gov/-/media/sde/school-nursing/forms/early_childhood_health_assessment_form.pdf
• CT Medication Authorization Form: https://portal.ct.gov/DPH/Health-Education-Management--Surveillance/Asthma/-/media/Departments-and-Agencies/DPH/dph/hems/asthma/pdf/DaycareMedAdminpdf.pdf
• Individual Plan of Care Form (IPC): https://www.ctoec.org/wp-content/uploads/2019/03/Individual-Plan-of-Care-Sample-Form.pdf  

Medication Authorization forms are required for ANY student leaving prescription or over the counter medications at after school. Examples: inhaler, EpiPen, cough medicine, eye drops, etc.

• Medications must be submitted to the Site Director BEFORE your child begins after school.
• Students CANNOT carry medications on their person during after school hours. Do not send medications in your child's backpack.
• Students with medication listed on their physicals MUST submit medications unless detailed otherwise in an IPC form.

An Individual Plan of Care form is designed to inform any staff interacting with your child on any special circumstances regarding their care OR any history/knoweldge you feel is relevant for us to know. This form is NOT limited to only medical conditions. The following examples would require an IPC form:

• Medications
  • Example: My child has an EpiPen for emergencies or my child needs to take their inhaler every day at 12pm.
• Allergies
  • Example: My child is allergic to ingesting peanuts, but not contact with peanuts or my child can ingest cooked eggs but cannot touch/eat raw eggs.
• Medical Conditions (including neurodivergency)
  • Example: My child has frequent nose bleeds or my child may experience seizures.
• Physical Limitations/Concerns (including hearing, speech and/or vision)
  • Example: My child easily dislocates their right shoulder, prevent any roughplay or my child is hard of hearing, speak to them directly to their face.
• Activity Limitations or Restrictions
  • Example: My child cannot swim because of epilepsy or my child is very nervous of heights.
• Behavior Habits/Concerns
  • Example: My child is easily distracted when traveling or my child yells/pushes when they are upset.
• Useful Verbal or Behavioral Cues (from home, school or doctors)
  • Example: My child likes a book when they feel overwhelmed or my child understands not to push when we say "XYZ" at home.
• ANY entry under the medical, behavior, dietary and/or religious after school registration sections of online registration requires an IPC form.
• ANY medication or medical condition indicated on the heath assessment record by a physician requires an IPC form.
  
  • If a medication/condition is no longer relevant, on the IPC form state the reason "ex: asthma" and "no longer relevant."