Date: ______________________

Student: ________________________________________________________________

Parent/Guardians Signature: _______________________________________________________________

I hereby give permission to the Medical Center of Central Georgia and the Peach County School District for my child/ward to participate in the following services offered by the School Nurse Program which I have checked below. I understand that I can revoke this permission at any time by written notice to the school.

• General Primary nursing care
  
• Routine physical examination
  
• Nursing care and treatment of acute illness
• Nursing care of chronic illness
  
• Referrals for illness not suitable for nursing care and/or Treatment in the school clinic
• Blood sugar and/or Hemoglobin monitoring
• Medication administration (Tylenol, Advil, Maalox, Benadryl, Chloraseptic, etc.)

• Dental Screenings
  
• Health Education
  
• Wound Care (Bactine, Caladryl, Antibiotic, Antifungal, and Hydrocortisone creams)
• Vision/Hearing Screenings
  
• Nutrition education
  
• Weight reduction Programs
  
• Blood pressure monitoring
  ________________________________________________________________________
  Directions: This form must be completed and on file in the clinic before any services are rendered.
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