2023/2024 SACC Medical Forms

Medical Forms

Be sure to include your child’s name and school on the medical form. It is your responsibility to make sure all questions are answered correctly, especially if your child / children has any food / medication allergies, or any medical or developmental conditions requiring special attention.

Special Health Care

If your child has special health care needs, please discuss these with the Director at the School Age Child Care (SACC) Office, prior to registration, to assist SACC in properly caring for your child in case of emergency.

Children who have special health care needs are those who have chronic physical, developmental, behavioral or emotional conditions expected to last 12 months or more and who also require health related services of a type beyond that required by children generally.


If your child requires an asthma inhaler/nebulizer or epi-pen, it must be brought to the SACC Program the first day the child attends the program. It must be in the original container with the child’s name on the label. The parent must ensure that the epi-pen and inhalers are kept up to date; once they expire, they must be replaced.

It is also the parent’s responsibility to instruct each individual School Age Child Care Staff Member of the use of the epi-pen’s and inhalers. Please keep in mind, we are not able to accept and/or dispense any epi-pens or inhalers unless all forms are completed and submitted to SACC Office.

Please print the appropriate form(s) for your child. If the medical form is not filled out, DO NOT WAIT to return the remaining pages of the registration packet. Medicals are due in our office no later than August 1, 2023. No medical forms will be accepted prior to registration.

Medical Form - No allergies (PDF)

Medical Form- Allergy- No Epi-Pen Required (PDF)

Medical Form - Epi-Pen (PDF)

Medical Form - Inhaler (PDF)

Please note: A physical is not required if performed within the past 2 years; information can be taken from existing medical records. A medical professional (other than a relative) must complete this form. Please be sure that the medical form is both signed and stamped at the bottom.