I have provided all medical, behavioral, and legal information necessary for staff to understand my child's needs and to provide safety for my child and others, including emergency contact information. I give my permission for the school nurse to contact my child's physician(s), and/or teacher(s) to discuss needed information contained on this form. I acknowledge that the dates for State Mandated Screenings are as follow: Vision/Hearing- September-May and BMI/Scoliosis-January-February and that if I decline any of these screenings it must be in writing. I also understand that unless indicated as an allergy above, my child will be treated with basic first aid, which includes but is not limited to: Bio Freeze, Calamine Lotion, Cool Jel Cooling Cream, Hydrocortisone Cream 1%, Lip Balm, Lotion, Lozenges, Orajel, Peppermints, Refresh Eye Drops, Triple Antibiotic Ointment, Vaseline, or Zinc Oxide Ointment.
In compliance with the Family Education Rights and Privacy Act (FERPA) (20U.S.C. & 1232g; 34 CFR Part 99), I give permission for my child's personally identifiable information/student education records to be disclosed to Third Party Billing Vendor for the purpose of billing Medicaid and/or private insurance. In compliance with the Family Education Right to Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) I give permission for my child to participate in the School Immunization Clinic. I understand that the appropriate Arkansas Department of Health consent forms will be provided for my consideration prior to the clinic.