Dear Parents:

The Peach County School Nurse Program will be providing services in your child's school this year. If you would like your child to participate, please read and sign below.
Thank you and please let us know if we can help you and your child or answer any questions.

Date _____________________________________

Child's Name __________________________________________________________________________

Grade: ___________Age: _______Race: ______________________________ Sex: __________________

Date of Birth: ____________________ Doctor's Name: _________________________

Allergies (Medicine / Food): ______________________________________________________________

Health Problems: ___________ Asthma___________ Diabetes__________ Seizures _________Sickle Cell

Other:_________________________________________________________________________________

Does your child take medicine at home or at school? ____ Write the medicine name below:

______________________________________________________________________________________

Parent's name: _________________________________________________________________________

Address: ______________________________________________________________________________

Phone Number: __________________________ Work Number: __________________

Who should we contact in an emergency? ____________________________________________________

Emergency Phone Number (not yours) ______________________________________________________

Do you have any religious or cultural needs the school nurse should know

about?_________________________________________________________________________________

Please notify the nurse of any new health problems so that we can help your child with medicines or questions.

Parents or legal Guardian's signature: _______________________________________________________

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