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Fax: (315) 701-9555
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School / Camp / Daycare Note Request Form
Need a note for school, daycare or camp? Please fill out the note request form in its entirety, below!
Please note the following:
If the patient is under the age of 18, all requests must be submitted by the patient's parent or guardian.
At this time, we are only accepting request forms through our website.
Please allow up to 7 business days for completion of forms. While we make every effort to accommodate all requests promptly, processing times may be extended during periods of high request volume.
Documentation requests require that patients have been seen for follow up care within the previous 12 months.
Because of its time consuming nature, there will be a $5 fee for each completion of the NYS Office of Children & Family Services Individual Allergy & Anaphylaxis Emergency Plan. This fee must be paid prior to completion of request.
For basic school or camp notes (not including the above NYS Anaphylaxis Emergency plan), an annual note can be completed at no charge. Any additional revisions or reissued notes will incur a $5 fee, which must be paid prior to processing.
Request Date:
Tuesday, January 27, 2026
Name of Person Requesting Form *:
Contact Phone Number *:
Relation to Patient *:
Name of Patient *:
Patient Date of Birth (mm/dd/yyyy) *:
Patient Current Weight:
Is this child authorized to carry medicine and/or self-medicate? *
Yes
No
May carry, adult administer
Venom Allergy?
Yes
Food Allergies
Yes, List foods, separate by comma
Note Type:
*If unsure of specific note, please check with daycare or camp
Select Type of Note
School Note
NYS 2021 Form + $5.00 Fee
Daycare Note - NYS 2021 Form + $5.00 Fee
Camp Note
Other
Medications that need to be listed in note:
Check all that apply
EpiPen 0.3 mg
Benadryl
EpiPen JR 0.15 mg
Albuterol rescue inhaler
Epinephrine 0.3 mg
Xopenex rescue inhaler
Epinephrine 0.15mg
Albuterol nebulizer solution
Auvi-Q 0.3mg
Xopenex nebulizer solution
Auvi-Q 0.15 mg
Other
Auvi-Q 0.1 mg
How would you like to receive the note once completed?
1 Copy is provided. If additional boxes are checked, the completed note will be held for pick up.
Mail
- There will be a $1.50 fee.
Fax
Pickup at the office
Email
Any additional instruction/request, please add in comment box.
Comments:
Signature of Person Requesting Form *
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5229 Witz Drive,
North Syracuse, NY 13212
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