I give permission to Healthy Learners to provide services to my child. These services may include a professional medical evaluation and treatment, as well as transportation to and from school to their appointments. I understand that the information about my child that I provide to Healthy Learners will be shared with their health care provider partner(s), as well as with other covered entities that need this information to assess, evaluate and treat my child’s health care needs or process payment for services provided to my child. Examples of these groups include health insurance plans like Medicaid, and the SC Revenue and Fiscal Affairs Office. I understand that the healthcare team will share health information about my child with Healthy Learners so that Healthy Learners can tell me about the visit. I give my permission to all members of the team to exchange health information. I understand that my child’s participation is voluntary. This consent will remain valid as long as my child is enrolled in school.

Healthy Learners summarizes information about children served for program planning, to measure program outcomes and impact, and to secure the grant funding needed to continue providing services to children at no cost to families. Information collected may include health care data provided by the SC Revenue and Fiscal Affairs Office. My child may be asked to participate in an evaluation survey. All information obtained will be kept confidential except as otherwise required by law. Completed evaluation reports are publicly available, contain only information that is summarized or grouped together, and do not use any names or identifying information. I understand if I do not wish for my child to be included in Healthy Learners program evaluation measures, I should submit a signed, written letter to Healthy Learners at 2711 Middleburg Drive, Suite 304, Columbia, SC 29204. Participation in the program evaluation is not required in order to receive services from Healthy Learners.

I give the school district permission to provide my child’s school data, including attendance, grades, discipline, and standardized test scores/results for the purpose of tracking the impact and success of the Healthy Learners program. I authorize Healthy Learners to request, receive and use this information for all years of my child’s enrollment to establish a before and after baseline; data will be used to track the impact of services on my child. I may ask for a copy of any records about my child that Healthy Learners has received from the school district.

I understand that Healthy Learners promotes its services to encourage student participation,engage the community, and solicit donations. Promotion may include photographs. Children are never identified by name. I give my permission to photograph or video/record my child’s image for promotional/educational purposes. Note that you may still receive services even if you do not give permission.

I, on behalf of myself, my child and my heirs hereby RELEASE AND HOLD HARMLESS HEALTHY LEARNERS FOR ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF HEALTHY LEARNERS, its donors, sponsors, board members, employees and agents OR OTHERWISE, except in the case of gross negligence and/or intentional misconduct. I HAVE READ THE ABOVE PERMISSIONS AND RELEASE FROM LIABILITY, UNDERSTANDING ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP CERTAIN RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY PROMISES OR THREATS.