PARENT PERMISSION FORM

______________________________________ _________ _______________________

Student’s Name Grade Date

I understand that I have a choice between a physical examination by a family physician at parent’s

expense or a school examination by the school health provider.

Please check below and return as soon as possible.

_________ School Physical Examination	_________ Private Physical Examination
_________ School Dental Examination	_________ Private Dental Examination

If the Private Physical/Private Dental forms are not returned, your child will be scheduled

For a school examination.

_____________________________________

Signature of Parent or Guardian

______________________________Cut Here________________________________________

LEBANON SCHOOL DISTRICT

FAMILY DENTIST REPORT

If this form, or a similar statement signed by your dentist, is not returned, your child will be examined by the

school dental examiner.

Student______________________________	Grade__________
School______________________________	Teacher__________________________

The above-named child last visited my office on _________________________(Date)

At that time all necessary corrections were made yes_______ no_______

This child is currently under treatment yes_______ no_______

DENTIST’S SIGNATURE__________________________________________