C: 848 242 1818 | Email:info@middlesexcharter.org

Nurse Forms

Forms

Asthma Forms

These forms are for asthma management. Includes asthma emergency treatment plan and medication prescription forms.

Asthma Form

Allergy Forms

These forms are for allergic reaction management. Includes emergency treatment plan and medication prescription forms.

Allergy Forms

Diabetes Management plan

For the student with diabetes. All forms must be completed appropriately and medications provided to the school nurse no later than the 1st day of the school year.

Diabetes Management Forms

Seizure Management Plan

This for students with seizures, form should be completed appropriately and submitted to the Nurse with any prescribed medication no later than the 1st day of the school year.

Seizure Management form

Health Physical Form

Needed by the health office for health history updates. Completed by parent and student`s Physician or Advanced Practice Nurse (APN). Please attach immunization records.

Health Physical Form

OTC and Prescription Medication Form

This form is for prescription and Over the Counter (OTC) medications. Must be completed by parent and physician before medication can be administered at school by the school nurse.

OTC and Prescription Medication Form

Authorization for Administration of OTC Medication for Acute Illness at School

The school physician has authorized the administration of Tums, Ibuprofen, and Tylenol if needed with parent`s/guardian`s permission.

OTC Medication for Acute Illness Form

Stay Connected

Find Us on Social Media.

About Us

  • A public school serving grades Kindergarten through 5.
  • Open to all students who reside in the City of Perth Amboy.
  • A replication of the Central Jersey College Prep Charter School, a recipient of the 2016 Blue-Ribbon Award, cjcollegeprep.org

Contacts

430 Market St. Perth Amboy
NJ 08861 USA
This email address is being protected from spambots. You need JavaScript enabled to view it.This email address is being protected from spambots. You need JavaScript enabled to view it.
  848 242 1818
Fax: 848 242 1818