Health Exam Forms

  • Please print the forms below and bring to your Health Care Provider...


    Please note, the Health Exam Form and the Immunization Form provide the information mandated by New York State.  However, your child’s Pediatrician’s office can print out this information on their own form and it will be accepted for this academic year by the school district.  You may request this information directly from your Pediatrician or print out the appropriate forms below to be completed by the Pediatrician.  The Health Examination Form and the Immunization Form must be signed and dated by a New York State Pediatrician and can be mailed, dropped off, faxed or emailed to the Mount Kisco Elementary School Nurse.  A current Health Exam is dated on or after September 1, 2021. It is now more important than ever to keep up with your child’s well visits and remain up to date with immunizations. New York State Education Law requires children to have a physical examination if they are entering entering Kindergarten, grades 1, 3, 5, 7 and 11 and all newly enrolled students in all grades. Dental visits are also important and the Dental Form is provided below.

    If your child will require medication to be available during the school day, the appropriate Medication Administration Forms are below and need to be completed and signed by the doctor.  All medications are kept in the Health Office and require a doctor’s signature along with a parent signature on the noted form.  


Health Forms