Nurse’s Office » LMS Nurse’s Office

LMS Nurse’s Office



TO:             Parents / Guardians

FROM:       Dianne Donohue-Hand, RN, MA, CSN


Below are forms that you may needNurse’s Office for your child to be completed by your doctor.  All forms can be downloaded.  All medication forms are valid only for the school year in which they are written and  NEED TO BE RENEWED EACH SCHOOL YEAR.

 Asthma Action Plan – If your child has a history of asthma, or uses an inhaler, or a nebulizer please have your physician complete the form for self-administration and signed by a parent.

Allergy Form – If your child has allergies and is prescribed Epinephrine, please have your physician complete the form for self-administration and signed by a parent.

Medication Form - If your child needs to take medication daily during the school year, or you want to have medication in school for your child, such as Tylenol or Cough Drops, or any other over the counter medication, a medication form needs to be completed by your physician and signed by a parent and a parent must bring the medication to school in the original package.                                           

No medication can be administered without a doctor’s order and parent consent.  All medication must be brought to the nurse by an adult in the original container with the student's name, the medication name and dose to be given, and the doctor’s name clearly on the container.    

No Longer Medical Condition - If your child no longer needs medication for any known medical condition, have the doctor complete this form.

Athletic Pre-Participation Physical Form – This is the physical required for all seventh graders. The physical is also required for any student who wishes to participate in any extracurricular sports program.  Any doctor completing a Pre-Participation Physical must provide the date that they completed the Cardiac Assessment Professional Development Module or the physical is not valid. 

Any student that has a medical condition that needs medication such as an Inhaler or an Epi-Pen and does not provide a doctor's order and the medication to school will not be allowed to participate in sports or be allowed to participate in Field Trips.

Doctors from out of state, such as New York or Connecticut must also complete the Cardiac Professional Development Module.


Permission to Share Information – If your child has any medical conditions, this form gives the nurse permission to share pertinent medical information with other school personnel; to protect the health and safety of your child.
Medical History Questionnaire - To be completed by new students.

Guidelines on when to keep your child home. 


If your child is returning to school with an injury, please obtain a doctor's note for the use of CRUTCHES and use of the elevator: The note must clearly state that the student is allowed to use crutches in school, and to allow the student to the use of the elevator.  It must also state the nature of the injury, expected time of recovery, and dates the student is excused from physical education and sports.

If you have any questions or you would like to discuss any health issues your child might have, please call Ms. Donohue-Hand at 201-302-5200, ext. 3209.  You may mail or drop off forms to the attention of Ms. Donohue-Hand, School Nurse at Leonia Middle School Main Office.