I understand that this eligibility certification form is a legal document and certifies that the information on this form is true to the best of my knowledge. I acknowledge that such information is subject to verification and that falsification of the form shall be grounds for termination from the program. All such information will be kept confidential.
I give permission for myself/my child to receive treatment by UCHC Mobile Unit at the School Based Site, and without the parent/guardian present.
I understand that I may have my prescriptions filled at any pharmacy.