Form Sts0144 Orthopedic Injury Assistive Device Authorization Form


St. Lucie Public Schools
Student Services
Orthopedic Injury Assistive Device Authorization Form
__________ _____
Student Name
____ ___________
_______ _____
School Name
Dear Parent/Guardian:
In order for your child to use an assistive device during school hours, the school will need the
information on this form from you and the health care provider. Please return this completed form
to the school health room.
This section is to be completed by the parent/guardian
Medical Release
It is necessary for my child ________________________________to have a special assistive
device during school hours. I hereby give permission for release of medical information pertaining
only to the orthopedic injury and prescribed assistive device to the School Board of St. Lucie
County, Florida. This device will be supplied and maintained by me and will arrive at the school in
working order daily. The school and St. Lucie County Health Department personnel will assume
no responsibility for the proper maintenance or delivery of the special assistive device that is
Assistive device supplied by the parent: ___________________________________
Parent/Guardian Signature: _______________________________Date:____________
Parent/Guardian Printed Name: ___________________________Phone #:__________
Parent/Guardian Address: ________________________________________________
This section is to be completed by the treating physician
Type of Injury__________________Location______________Date of Injury__________
Activity Level (please check)
□Non-weight bearing
□Partial weight bearing
□Weight bearing to tolerance
□Full weight bearing
Assistive device(s) to be used □Crutches
□Other _____________
Has the student been instructed in the use of crutches, or other assistive device(s)? □Yes □No
Comments/Special Instructions/Restrictions___________________________________________
This order is effective until_____/_____/_____
Physician’s Signature_______________________________________Date__________
Physician’s Printed Name___________________________________Phone_________


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