HEALTH SERVICES IN SCHOOL SETTING NOTICE
Dear Decatur County School Parents/Guardians,

Parent/guardian permission is required for health services performed in the school setting form, please fill out the form below to give permission to school nursing staff to perform non-emergent medical care to your child...

Health Services in School setting
Pursuant to the requirements of. T.C.A. § 63-1-173, students cannot receive non-emergent medical care absent parent consent. This may include, but is not limited to, cleaning and bandaging minor cuts or abrasions,
providing and ice pack, or managing illnesses and or injuries that can occur during a school day. If consent is
provided, it will remain in effect during the school year unless withdrawn in writing by the parent/guardian.
Sign in to Google to save your progress. Learn more
Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Student School *
 Do you give permission for your student to receive non-emergent health services in the school setting:   

  *If no is selected, please ensure that your student understands they cannot go to the school nurse to receive treatment outside of an emergency. Parents will also be expected to ensure they are able to provide necessary treatment within 30 minutes of notification.   
 *
Parent Name (E-Signature) and Date *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Decatur County School System.

Does this form look suspicious? Report

Google Forms