Fill and Sign the Permission Form 497331562

Medical Permission Form for School ________________________ (Name) School District __________________________________________ (Post Office Address or Street Address) ___________________________________________ (City, State, Zip Code) Phone No. ________________ FAX: _________________ Student Name _____________________________________________ Name of School ____________________________________________ Date of Student ____________________________________________ __________________ (Name of State) law requires school districts to ensure medical compliance and the maintenance of specific records on each student enrolled in school. To do this in an orderly and expeditious manner our desire is to use available medical personnel for routine services, and if needed, emergency medical service. If an emergency arises every effort will be made to contact you as soon as possible before anything is done. It is also necessary for the school district to obtain, for student records, relevant medical information, such as immunization records, hearing and vision test results from health care providers. Routine services may include physical examinations, vision screening, hearing screening, TB skin tests, health screenings, inoculations, etc., and does not include dental work or non-emergency medical services that may require your attention. Records to be obtained may include general health, vision and hearing screenings, immunization records, and physical examinations. All data collected is confidential and will be used for legal obligations pertaining to records of the named student. For the student listed above, your signature will authorize official school district personnel to receive related medical records and, if needed, the opportunity to obtain emergency medical service when you cannot be contacted. It will also authorize release of hearing and vision screening results to Norton Sound and allow them to share their results with the school district. Thank you. ___________________________ (Printed Name of Parent/Guardian) ___________________________ (Signature of Parent/Guardian) Date _____________________ Note : Please use one form per student. If you cannot sign for whatever reason so note and return to the school principal. Please return by ______________________ (date) .