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. Yog koj muaj lus nug los yog xav tau neeg pab txhais lus, thov hu rau koj lub tsev kawm ntawv.

NS M-14                                                                                     Clovis Unified School District                                                     Rev. 5/23 PARENT/GUARDIAN REQUEST & PHYSICIAN'S ORDERS FOR STUDENTS WITH SEIZURE DISORDERS TO PARTICIPATE IN SWIMMING PROGRAM AND WATER PARK ACTIVITIES

Dear Parent/Guardian:
For the safety of your child and as part of Clovis Unified School District's guidelines for students with seizure disorders to participate in swimming activities, the following must be done before a student with seizures (or taking medication for seizures) can participate in swimming.

1.	The student’s physician must give written permission for the student to participate in swimming/water park activities.
2.	A parent/guardian signature stating the student may participate in swimming/water park activities following the physician’s recommendations.
3.	OPTIONAL: Recommend student to wear a medic-alert bracelet/necklace.

If you have any additional questions regarding the above guidelines, please contact me at:
Phone # (559) 327-	      Fax 559) 327- 	

Sincerely,

School Nurse: 	       School/Grade: 	

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

PHYSICIAN'S ORDERS:

Student’s Name 	               Birthdate 	

1.	Yes, the student is able participate in this year's school swimming program to include the following: Underwater swimming	Diving
Requires 1:1 adult supervision.

No, the student should NOT participate in this year's school swimming program.

In addition, please complete the following for all 6th and 8th grade students: 2.	Yes, student may fully participate in any water park with the following:
May participate independently at the water park.

(Which includes water slides, wave pool, rapid rides, stair climbing, etc.) Requires 1:1 adult supervision to participate in any water park.
No, the student should NOT participate in any water park.

Other/Special Instructions:

Physician's Name 	
(Please print or type)

Physician's Signature 	

Phone _______________________

Date ________________________

Address	City	State	Zip *************************************************************************************************

Parent's Signature 	               Date ________________________