School Letter Form
Kindly fill out the following form in its entirety and return to firstname.lastname@example.org or fax
to Laurie at 352-265-0857.
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?