Health Forms

Administration of Medication by School	Asthma Action Plan	Certificate of Religious Exemption from Immunization	Life Threatening Allergy Management Plan
Physician’s Authorization for Treatment to be Performed	Request for Self-Administration of Emergency Medication	Virginia School Diabetes Medical Management Form	Physical Education Restrictions Form
Seizure Action Plan	Diabetes Medical Management Plan	Special Dietary Needs Form	School Entrance Form – Medical

Tdap Booster

As of July 1, 2021, the NEW requirement is for one dose of Tdap (tetanus, diphtheria, pertussis) and one dose of meningococcal conjugate vaccine to be given for all children entering the 7th grade who have not already received it. Human papillomavirus (HPV) vaccine is also recommended for adolescents. When you schedule your child’s appointment to receive Tdap and meningococcal conjugate vaccines, let your health care provider know if you want your child vaccinated against HPV as well.

All rising 7th grade students are required to have the necessary boosters prior to entering 7th grade. You may get the Tdap vaccine from your child’s health care provider or at the Chesapeake Health Department. The Health Department carries the brand name, Boostrix. Many health care providers use the brand name, Adacel, which may be given at age 11. When your child receives the Tdap vaccine, please send documentation, signed by a licensed medical provider, to Nurse Brooke Thompson as soon as possible. STUDENTS WILL NOT BE ADMITTED TO 7th GRADE WITHOUT THIS IMMUNIZATION. (THERE IS NO GRACE PERIOD). If the vaccine is given after the last day of this school year, you will need to bring the documentation to the front office at Hickory Middle School.

Routine required immunizations are available at no cost to you for children 18 and under. Please bring the child’s shot record.

Chesapeake Health Department

748 N. Battlefield Blvd. (behind Chesapeake General Hospital)

757-382-8609