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Eyeglasses/Contacts Form

Required

Dear Parent or Guardian, To have a better understanding of your child’s vision it is important for you to let the school nurse know what if any restrictions are to be in effect in regard to their glasses. Please consult your eye specialist or physician and have them fill in the form below. PLEASE RETURN THIS FORM TO THE SCHOOL NURSE. Thank you for your cooperation.
Print Namerequired
First Name
Last Name
Must contain a date in MM/DD/YYYY format
3. Should glasses/contacts be worn during gym/recess?required
4. Should physical activities be limited because of eye condition? required
5. Are glasses/contacts to be worn for all class work?required
6. Are glasses/contacts to be worn for reading?required
7. Are glasses/contacts to be worn for writing? required
8. Are glasses/contacts to be worn for board work?required
10. Have shatterproof lenses been recommended?required
Exam findings:

Near Vision:

Near Vision Corrected:
Distance Vision:
Distance Vision Corrected:
Attach up to 1 file with a maximum size of 10MB
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Must contain a date in MM/DD/YYYY format
Attach up to 1 file with a maximum size of 10MB
No file chosen
Thank you, Nyack Public School Nurses

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