Forms

Rushville Middle School
6409 Cincinnati-Zanesville Road NE
Lancaster, OH 43130
Phone: 740-536-7249
Fax: 740-536-7211

Middle School Forms

Archived News

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.

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 capabilities required.)

Print the application form here Work Permit Application Forms.

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Forms

Middle School Forms

Immunization Exemption Form

Pre-Participation Physical

Dispensing Medication Form

Open Enrollment Application

Student Accident Insurance Plans 2022-2023

Work Permit Application and Process