Date: ____________

Dear Parent/Guardian:

A personal hygiene and development video will be shown as part of our health education program on __________________________ at ___________________________. If you would like to preview this video before it is shown, please contact me at the above phone number.

Only those students whose parents sign the permission form will be permitted to attend. Please sign the bottom of this form and return it to school tomorrow.

_______________________________

School Nurse/Nurse Practitioner

____ I hereby grant permission for my son/daughter to view the video

____ I do not grant permission for my son/daughter to view the video

___________________________ _________________________________

Student Name                                      Parent/Guardian Signature and Date