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Blanket Consent Form for Health Care Services for Minor Children

Please complete the form below. Required fields marked with an asterisk *

Providing blanket consent is optional and may, instead, be given on a case-by-case basis.

Dear parent or guardian,

The purpose of this form and the attached copy of the District’s policy on Student Health/Physical Screenings/Examinations is to provide notice of all health services offered or made available through the school by the District or by any private organizations and to provide notice of the District’s policy on physical examinations and screening of students and to obtain parent/guardian consent for these services.

The District will provide, under reasonable circumstances, nonemergency first aid services to a child appearing or representing to be sick or injured, such as dressing minor wounds, applying topical agents, providing fluids or ice, and performing checks to identify minor illnesses.

The District may also provide health care services without parent/guardian consent if District staff reasonably determines that a medical emergency exists and:

1. Furnishing the health care service is necessary to prevent death or address a serious bodily harm to the minor child; or

2. District staff can’t contact the parent/guardian despite a reasonably diligent effort, and the health care service is furnished to prevent loss of life or serious physical illness or injury to the minor child.

____________________________________________________________________________________________________________________

By checking the below boxes, it indicates that I give permission to Conduct the Health Service or Exam. The District will provide the following additional health services or examinations which can only be provided with parental permission or in the event of an emergency as described below: *

Answer required for "By checking the below boxes, it indicates that I give permission to Conduct the Health Service or Exam. The District will provide the following additional health services or examinations which can only be provided with parental permission or in the event of an emergency as described below: "

Preventative health and wellness services and screenings as described in Policy 3500

Administering or assisting with the administration of medication as described in Policy 3510

Emergency care as described in Policy 3540

Appropriate management of all health conditions with parental consent

Any health services the District deems appropriate

Parent 1: Emergency Contact Information

Name*

Answer required for "Name"

Phone*

Number Required

Email*

Answer required for "Email"

Parent 2: Emergency Contact Information

Name*

Answer required for "Name"

Phone*

Number Required

Email*

Answer required for "Email"

I hereby designate the following emergency contact for my child and grant them authority to consent to health care services provided by the school in the absence of the school’s ability to reach me.*

Answer required for "I hereby designate the following emergency contact for my child and grant them authority to consent to health care services provided by the school in the absence of the school’s ability to reach me."

Emergency contact 1

Emergency contact 2

Both Emergency contact 1 & 2

I do NOT wish to designate an emergency contact to consent to health care services provided by the school in the absence of the school’s ability to reach me.

Student Name*

Answer required for "Student Name"

Parent/Legal Guardian Name*

Answer required for "Parent/Legal Guardian Name"

Parent/Legal Guardian Phone*

Number Required

Parent/Legal Guardian Signature*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"