School Letter Form

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					School Letter Form
Kindly fill out the following form in its entirety and return to lfiske@peds.ufl.edu or fax
to Laurie at 352-265-0857.


Patient’s Name:
Please list fax number signed school letter should go to:


Please list current eating & cornstarch schedule along with current cornstarch doses:




Please list new changes needed (i.e. wake up time, new snack times, new breakfast time,
new lunch time, etc….):




What time does school start and end?

When will the patient need to leave the house?               Return to house?

Will he/she be taking the bus or walking to/from school?

What time is gym/recess?

Do you prefer your child’s glucose to be monitored regularly at school?
If so, what times?

Will your child need to carry any supplies or emergency rescue items on his/her person
while at school?
If yes, please list all items.


Are there any special requests you would like included in the school letter?