Health Services Back to School Forms



Dear WPSBC Parent/Guardian: 

Although we are still in the process of planning for what a return to school in August will look like, we are hopeful we will be back on campus. Therefore, we have prepared the back to school forms as usual.  

Please see the necessary forms and their corresponding due dates below. The forms are attached at the bottom of the page. The medical authorization and order for school-based therapy must be medically signed before return. 

If you would like printed copies of these forms, please call and leave a voice message at (412) 621-6009, or email Elena Flores-Noel at 

Forms: Must be Returned by:
Annual Consent Form August 21
Health and Emergency Contacts Update August 21
Medical Authorizations August 14
Authorization to Release/Obtain Information August 14
Medical Order for School-Based Therapy Services August 14

ALL medications, treatments or tube feedings given at school, including over the counter preparations such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), and cold medications, require medical orders completed by a health care provider licensed to prescribe in Pennsylvania. This includes physicians, nurse practitioners and physicians’ assistants. Under Pennsylvania state law, the signature of a nurse, unless a nurse practitioner, is not acceptable.  

Return signed forms by: 

  • Sending a secure fax to (412) 621-8965 at any time 
  • Mailing to Western Pennsylvania School for Blind Children, 201 North Bellefield Ave, Pittsburgh PA 15213, “ATTN Donna Salovay”
  • Scanning and emailing to 

If your child is seen by a health care provider, including an eye care professional, this summer or any time during the school year, please ask that the School receive a copy of the report, “ATTN Donna Salovay”. Release forms for these visits, as well as additional copies of the forms, are available at  

Please let us know immediately if your contact information and/or phone number has changed. We will be working this summer if you need to contact us for any reason. 


Elena Flores-Noel CRNP               Donna Salovay
Health Services Director                Registrar
412-621-0100 x242                        412-621-0100 x222 


Note: this information can also be found within the "Resources" tab on the website.