Dear Parent –Please complete for your child(ren) & return ASAP.
One less thing to do in September!!!!!!!
The Tuscarora School, in cooperation with the Tuscarora Dental Clinic and the NYS
Dept of Health is offering to all children a fluoride program to help reduce the risk of
tooth decay. Fluoride supplements are recommended for children who live in
communities with less than optimum levels of fluoride in their drinking water.
The supplements will be given under direct supervision. The ingredients include sodium
fluoride, lactose, saccharine, magnesium stearate and flavoring. The fluoride program is
safe & effective when the protocol is followed.
Fluoride supplements should NOT be given to a child both at home and in school on the
same days. Therefore, if your child is receiving fluoride supplements, he or she should
NOT participate in this program.
We encourage you to allow your child to participate in this valuable preventative
program. Your child’s participation is entirely voluntary and you may withdraw your
child from the program at any time. Your child may participate at NO COST to you.
This fluoride supplement program is, however, in no way a substitute for routine dental
care. Your child must continue proper home care and routine dental check-ups. Please
read and return the completed form as soon as possible. If you have questions please feel
free to contact me at the health office or you may contact the Tuscarora Dental Clinic.
Thank you,
Marilyn Schlehr RN 215-3672
-----------------------------------------------------------------------------------------------------------PARENTAL PERMISSION FORM
Supplemental Fluoride Program
___ I give permission for my child to participate in the fluoride supplement program
___ I do not want my child to participate in the fluoride supplement program.
___ My child takes fluoride supplements at home
Parent/ Guardian Signature_________________________________________________
Date________________________
Phone____________________________________
Address________________________________________________________________
Child’s Name_______________________________________ Grade in Sept_________
FOR 2015-2016 SCHOOL YEAR
Download

Fluoride Permission 15-16