El dorado union high school district



Download 19.31 Kb.
Date conversion15.05.2016
Size19.31 Kb.
EL DORADO UNION HIGH SCHOOL DISTRICT
Parent/Guardian Request & Physician’s Orders for Students

with a Seizure Disorder to Participate in Swimming Program
If you have questions or need the help of an interpreter, please call your school office.

Si tiene alguna pregunta o si necesita la ayuda de un interprete, favor de llamar a la oficina de su escuela.

(CHECK APPROPRIATE SCHOOL)



 EL DORADO HS (530) 622-3634

VISTA HS Fax (530) 622-1802

561 Canal St.

Placerville CA 95667


 PONDEROSA HS (530) 677-2281

3661 Ponderosa Rd. Fax (530) 677-2299

Shingle Springs CA 95682


 INDEPENDENCE HS (530) 622-7090

4675 Missouri Flat Rd. Fax (530) 642-2291

Placerville CA 95667



 OAK RIDGE HS (916) 933-6980

1120 Harvard Way Fax (916) 933-6987

El Dorado Hills CA 95762


 UNION MINE HS (530) 621-4003

MOUNTAIN VIEW HS Fax (530) 622-6034 6530 Koki Lane

El Dorado CA 95623



 SHENANDOAH HS (530) 622-6212

6540 Koki Lane Fax (530) 622-1071

El Dorado CA 95623

Dear Parent/Guardian:


Students participate in swimming instruction during their Life Fitness class with one teacher supervising 35 to 40 students in the pool. For the protection of students with a seizure disorder, the following must be done before a student with a seizure disorder can participate in swimming.
1. A written request from the student’s parent/guardian stating that the student can participate (see below).

2. The student’s physician must give written permission (see below) for the student to participate in swimming. RECOMMENDED: Student to wear a medic-alert bracelet/necklace.


Please complete the parent/guardian request below, then send this form to your physician to fill out and return to the school. If you have questions regarding the above, please contact either of the following school nurses at 530.622-7090 or by fax at 530.622-1887: Kelly James, RN, MS, ext. 7140; Karen Demmer, RN, BS, ext. 7117; or Diana Campbell, RN, BS, ext. 7103.


PLEASE RETURN OR FAX THIS PORTION OF THE REQUEST TO THE SCHOOL/FAX NUMBER ABOVE.


PARENT / GUARDIAN REQUEST

Student’s Name:

     

Student’s Birth Date:

     

 YES, I request that my child participate in the swimming program this year.

 NO, I do not want my child to participate in the swimming program this year. My child will be enrolled in an alternate Life Fitness activity during the swimming unit.



Parent/Guardian Signature:

X

Date:

     



PHYSICAN’S ORDERS


Student’s Name




 may  may not participate in the swimming program at school.


Special Instructions:


















Physician’s Name:




Phone:







(PRINT OR TYPE)






Physician’s Signature:

X

Date:







F5141.21D2 8/17/12


The database is protected by copyright ©essaydocs.org 2016
send message

    Main page