Lancaster County Medical Excuse Form printable pdf download

Lancaster County Medical Excuse Form

Name of Medical Facility:

Address of Medical Facility:

Phone Number:

Student Name:______________________________ Date/ Time of Appointment:_________________________

Time Student Left Appointment: _______________________________________________________

I examined the above‐named student and found him/her to be:

___ Too sick to perform adequately ___ At risk for public safety ___ Able to return to school

He/she should be excused from school from _____________ (date) to ____________ and may return on ______________ date.

Physician’s Name: ___________________________Physician’s Signature: __________________________ Date:________________

___ I have found this child to have on‐going health issues and a discussion between medical personnel and school personnel

would be valuable.

If above is checked, parent must select one of the below options. (This form is effective until the last day of the current school year.)

___ I hereby GIVE PERMISSION for the doctor or members of his/her staff to discuss this medical issue with the appropriate

members of the school staff, with the purpose of contributing to the overall well‐being of my child. (Sign below.)

___ I DO NOT give permission for the doctor or members of his/her staff to discuss this medical issue with members of the school

staff. (Do not sign below.)

___ I have signed and given permission previously during this school year.

Name of Parent/Guardian:____________________________Signature: ______________________________ Date:___________

Lancaster County Medical Excuse Form

Name of Medical Facility:

Address of Medical Facility:

Phone Number:

Student Name:______________________________ Date/ Time of Appointment:_________________________

Time Student Left Appointment: _______________________________________________________

I examined the above‐named student and found him/her to be:

___ Too sick to perform adequately ___ At risk for public safety ___ Able to return to school

He/she should be excused from school from _____________ (date) to ____________ and may return on ______________ date.

Physician’s Name: ___________________________Physician’s Signature: __________________________ Date:________________

___ I have found this child to have on‐going health issues and a discussion between medical personnel and school personnel

would be valuable.

If above is checked, parent must select one of the below options. (This form is effective until the last day of the current school year.)

___ I hereby GIVE PERMISSION for the doctor or members of his/her staff to discuss this medical issue with the appropriate

members of the school staff, with the purpose of contributing to the overall well‐being of my child. (Sign below.)

___ I DO NOT give permission for the doctor or members of his/her staff to discuss this medical issue with members of the school

staff. (Do not sign below.)

___ I have signed and given permission previously during this school year.

Name of Parent/Guardian:____________________________Signature: ______________________________ Date:___________

Lancaster County Medical Excuse Form