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This page may be
printed out and completed by a physician, licensed
nurse, midwife, or nurse practitioner for
admittance to the CFB School-Age Parent
Program.
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Student's Name
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_____________________________________________
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Student's Address
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_____________________________________________
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Student's Phone
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_____________________________________________
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Physician's Name
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_____________________________________________
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Office Address
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_____________________________________________
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Office Phone
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_____________________________________________
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For Physician's
Use Only (Must be completed)
I have examined this student
and test results indicate she is pregnant. Her
expected due date is:
_____________________________.
At this time I
recommend:
_____ She continue attending
classes daily on her school campus
_____ She be considered for
homebound study because of the following medical
reason:
Physician's Signature:
_____________________________________
Date: _________________
This form may also be
completed by a licensed nurse, midwife or nurse
practitioner.
Please complete and return to
School-Age Parent Liaison, Mary Grimes Education
Center, 1745 Hutton Drive, Carrollton, Texas
75006-6617, Phone 972.323.6450, Fax
972.323.6453
For additional information
from the Parenting Teacher, email
Dorothy Nichols, or
telephone her at 972.323.6441.
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