Health Forms

Immunizations

Exemptions are recognized only for specific medical or religious purposes as recognized by the law. The student must provide a valid Iowa State Department of Health Certificate of Immunization Exemption.

Immunization Requirements

Emergency Contacts

It is district policy that the school is supplied with an emergency number that can be called in case a child becomes ill or is injured. Emergency information can be updated during school registration or any other time during the school year. If the emergency contact is someone other than a parent or guardian, please be sure that person is aware that you have given their number as an emergency phone number. If, at any time during the school year, this information changes, notify the school immediately.

Required Health Forms for Enrollment

Required Health Forms by Grade Level
Required Student Athlete Registration (Grades 7-12)

Required Health Forms by Grade Level

If you do not see your child’s grade level in the list below, then no additional health forms or immunizations are required. If you are new to the district or the state and have specific questions, please contact your school nurse or your healthcare provider.

All Grade Levels (PK-12)

CCACSD Physical Form Grades PK-6) to be completed by a healthcare provider for all new students
CCACSD Physical Form Grades 7-12) to be completed by a healthcare provider for all new student
Immunization Record (or Medical Immunization Exemption Form signed by a physician or Religious Immunization Exemption Form (Where to find documentation of your student’s most recent immunizations):
- Your child’s healthcare provider/doctor
- Previous school
- Your state’s vaccine registry/Public Health Department
- Military records, if applicable

Kindergarten

3rd Grade

Vision Screening Form

7th Grade

*Meningitis booster and Tdap booster required. Update Certificate of Immunization by a healthcare provider. Iowa law requires boosters before the first day of school.

9th Grade

Dental Screening Certificate

12th Grade

*Meningococcal vaccine proof required for two doses (A,C, W, Y) or one dose if received when the student was 16 years of age or older.
Update Certificate of Immunization by a healthcare provider. Iowa law requires boosters before the first day of school. There is no grace period.

*Johnson County Public Health offers free immunizations for children, regardless of insurance status. To schedule an appointment, call (319) 356-6042.

Required Student Athlete Registration (Grades 7-12)

Annual athlete registration in Bound is required for all student-athletes in grades 7–12 in order to participate in any athletic practices or competitions.

If your athlete is under 18, a parent/guardian must complete registration through Bound.

Please complete the registration to ensure your student-athlete is eligible to begin participation This must be completed before the first day of practices.

Select the programs your student-athlete is intending to participate in. If you don’t select all of the programs now, you will be required to enter the information later. If the student-athlete decides to not participate in a program selected during registration, no additional action will be needed.

What You’ll Need Before Registering:

A completed physical form
You must upload the last page, titled "Medical Eligibility Form," to Bound. If a different form is used, you must upload the pages that provide the following information:
- Date of exam
- Doctor’s signature
- Medical eligibility confirmation
Consent for the Concussion/Brain Injury form is part of the Bound registration process. You are NOT required to upload this document.

Athlete Registration Links and Instructions

Step by Step Bound Registration Instructions: Link
Bound Login: Link Login on a desktop, I-Pad, laptop computer or an I-phone only! You will have better luck with the process.
Instructions to upload the Physcial Form: https://intercom.help/boundhq/en/articles/8288335-how-to-upload-a-physical

Need Assistance:

If you’re having trouble logging in or uploading the physical form, click the green button in the bottom right corner of the Bound site for support.

Additional questions? Contact:

Kurt Ronnfeldt – kurtronnfeldt@ccaschools.org
Mary Lou Grimm – marylougrimm@ccaschools.org

STUDENT ATHLETE FORMS:

The following forms are required for all students participating in school athletic programs.

Concussion Brain Injury Form - English

Concussion Brain Injury Form - Spanish

Iowa Athletic Preparticipation Physical Examination - English

Other Health Forms

Medical and Medication Forms

Medical and Medication Forms

School personnel cannot administer any medication during the school day, including prescription and over-the-counter medication, unless the authorization to administer medication form is completed. This form is also available at registration and in the school health office throughout the school year.

Diabetes Medication Self-Administration Consent Form

Diet Modification Request Form

Medication Administration Policy

Medication Self-Administration Consent Form - Asthma

Medication Self-Administration Consent Form - Epi Pen

Medication Parental authorization form for administration of medication to students