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740-536-7249
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Rushville Middle School
6409 Cincinnati-Zanesville Road NE
Lancaster, OH 43130
Phone: 740-536-7249
Fax: 740-536-7211
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Immunization Exemption Form
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Please note: Each form is listed twice. The first is in PDF format. The second is an RTF file which is required for compliance with the Americans with Disabilities Act.
Pre-Participation Physical
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Dispensing Medication Form
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Open Enrollment Application
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Student Accident Insurance Plans 2022-2023
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Work Permit Application and Process
State of Ohio - Work Permit Instructions
(Students 18 years of age or older do not need a work permit)
Completely fill out part 1 - Student /Applicant Information. The student’s parent/guardian must complete and sign this portion.
Complete pledge of employer section.
Make sure to include the Employer’s Tax ID Number and
tentative hours/days to be worked
Your employer must sign the pledge of employer section.
Student must have a current physical form filled out by a doctor (page 2 of the application).
Physicals are active for 1 year from the date performed. If there is a current athletic physical on file, we can use this. If not, page 2 must be presented with a doctor’s signature.
After completing steps 1-4, you have two options:
Bring the completed forms to the cashier’s office between the hours of 7:30 a.m. and 2:00 p.m. The student needs to be present to sign the official work permit.
OR
Email copies of the completed work permit application to Kathy Williams (
[email protected]
) and you can complete the process virtually. (Home printing capabiliti
es required.)
Print the application form here
Work Permit Application Forms
.
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View text-based website