All of these forms are required by the State to be on file before your child may attend EDSE. These forms must be turned in prior to your child's first day of school but no more than 2 months before the first day of school. Please do not substitute other school's or Health Care Provider's forms as they will not be accepted.
Once you have completed, signed and dated all the required forms, please return them to us either by mail (P.O. Box 1630 , Evergreen CO 80437), by bringing them to the office, or by faxing. Our fax number is 1-303-379-1509. The"1" must be used for the fax to go through, even for local faxes. Your Health Care Provider can fax the Immunization Record and the General Health Appraisal Form to us at the same fax number, as long as you have already filled out the "parent section" at the top of the General Health Appraisal Form.
Click on the tabs below to view and download the forms that you need.
Tips for Filling out the Required Forms:
1. All forms must be completely filled out, signed and dated.
2. Information regarding Hospital of Choice, local Health Care Provider, and Insurance which is located on the Emergency Healthcare Authorization Form must be completed. If you do not have a hospital of choice, you may choose to use the “nearest” hospital. If you have recently moved to the area and do not currently have a local Health Care Provider, you may leave that blank, however you must inform us in writing of your new Health Care Provider within two weeks of your start date.
3. Complete and sign the “Parent” section of the General Appraisal Form before you have your Health Care Provider fill out their section of the form. Your Health Care Provider’s signature, date, next well visit due date, and office stamp must be provided for the form to be valid.
4. Children needing medications during the school day and children with medical conditions such as severe food allergies and seizures must have special forms filled out by you and your Health Care Provider and returned to us four week before you child’s first day. This gives our School Nurse time to go over the required forms and discuss with you your child’s specific needs while attending EDSE.
5. If your Health Care Provider faxes us your child Immunization Record, you do not need to have him/her fill out the Immunization Certificate provided in packet of required forms.
6. Completed forms may be handed into the EDSE Office, scanned and emailed to email@example.com, or faxed to 1-303-379-1509. The “1” must be used for the fax to go through, even for local faxes.
7. If you choose for your child to be Exempt from immunizations, , please contact Jerri Avery, our school nurse (firstname.lastname@example.org). Our Immunization Policy prevents us from falling below 90% immunization compliance. This limits the number of children we can accept into our program who have immunization exemptions. The number of children who can be accepted is determined by the number of children enrolled and is on a first-come, first-served basis. Our school nurse will provide the required Immunization Exemption Form.
These forms are for medical conditions or developmental milestones. All forms except for the questionnaires require your Health Care Provider to complete.'
Please contact Jerri Avery, RN, the School Nurse, if your child requires medication or has a medical condition and she will inform you which forms you must provide. She can be reached at email@example.com or by calling EDSE office at 303-674-9253.
Authorization for Exchange of Health Information Only (pdf)Download
Doctor's Order for Medication Administration at EDSE with Parent Permission (pdf)Download
Severe Allergy Questionnaire (pdf)Download
Colorado Allergy Anaphylaxis Emergency Plan (pdf)Download
Questionnaire for Parents of a Child with Seizures (pdf)Download
Seizure Action Plan (pdf)Download