Tech - Parent Guardian Consent

Youth's Name *

First NameLast Name

School*

Birthdate*

Date

Name of Parent/Legal Guardian*

Address (street, city, state, and zip code)*

Phone Number *

Gender*

MaleFemaleOther

Social Security # (if applicable)

Ethnicity*

Language*

Type of Insurance:*

I/We have read and understand the services offered at the School Health Center as described below. I/We understand that the services authorized by my/our signature on this form are limited to routine health services and treatment which may include, but are not limited to:

Diagnosis/treatment of minor and acute illnesses; first aid for minor injuries
Assistance with chronic (on-going) illnesses
Physical examinations for well-checks, sports, or pre-employment clearance
Immunizations
Laboratory services
Vision services that include eye exam and prescription eye glasses – AT PARTICIPATING SITES ONLY
Over-the-counter and basic prescription medications
Mental/Behavioral Health Counseling
Education concerning: nutrition; drug and alcohol abuse prevention; violence prevention; mental health; sexually transmitted disease and pregnancy prevention
Referrals for health services which cannot be provided at this clinic
Other services, including fifitness training, group exercise classes and referrals to social services including legal assistance

Please note: California State Law (California Family Code 6924-6929) permits for the provision of certain services to adolescents, 12 years and older, with or without parental consent. These services include: diagnosis and treatment of sexually transmitted infections, HIV counseling and testing, pregnancy counseling and testing, contraceptives, referrals for prenatal care, and mental health counseling in situations specified by the law.

Please list any services offered at the School Health Center you do not want your child/ward to receive:

Dental screenings and treatment – AT PARTICIPATING SITES ONLY During school-wide dental screenings, a licensed dental professional will examine your child's teeth and determine if they are in need of dental care. This screening does not include x-rays and does not replace an in-office dental examination. If a problem is detected, you will need to make a follow-up appointment with your dental provider; or the School Health Center staff may be able to assist you with a dental appointment on-site.*

I would like my child to participate in the school-wide dental screeningsI would not like my child to participate in the school-wide dental screeningsI would like my child to receive dental services at the School-Based Health CenterI would not like my child to receive dental services at the School-Based Health Center

I/We understand that this consent covers only those services provided at the School Health Center and no other private or public health facility. I/we hereby authorize a physician and other professional Health Center staff to provide necessary and/or advisable treatment for my daughter/son/ward. This student has my/our permission to receive all services offered at the School Health Center, except those that I/we have specifically excluded above. Students may be asked to register for Medi-Cal at the Health Center. In some instances family income may be a factor in determining eligibility; eligibility may depend on the type of medical or mental health service utilized by the student.

Medical records will be kept confidential. However, I/we acknowledge that the services for my child's condition may require the collaboration of other agencies and services providers. I/We understand that this collaboration may require the disclosure of information about my child to one or more service providers to facilitate coordination of services for my child. I/We acknowledge that the School Health Center may be required to release information regarding treatment to third-party payers, such as Medi-Cal, for the purpose of billing. Additionally, records may be released for any reason in accordance with acceptable medical practice and pursuant to law, including, but not limited to the following reasons: (1) If a student expresses a will to hurt herself/himself; (2) If a student expresses she/he may hurt someone else; and, (3) If a student claims someone is physically, sexually, or emotionally abusing her/him.

PARTICIPATING IN A COUNTY-WIDE EVALUATION OF SCHOOL-BASED HEALTH CENTERS

In order to improve our services, we are participating in a County-wide evaluation of School-Based Health Centers. The evaluation is being conducted by the University of CA, San Francisco (UCSF As part of this evaluation, we collect information on clients who use our services and share this information confidentially with UCSF. UCSF will never share your name or your child/ward's name or other personally identifying information in any evaluation reports.

By signing below, you are consenting to the following:

I, parent/legal guardian below, authorize the School District to grant La Clínica de La Raza, the on-site provider at my child's school authorization to review my daughter/son/ward's student records. La Clínica de La Raza agrees not to disclose the student's records to any other person or entity without first obtaining my written permission.

I understand that La Clínica de La Raza may share my child's information with my child's provider for the purpose of medical evaluation and treatment. This consent form will remain in effect until this student's enrollment terminates, or until I/we revoke this contract in writing.

Parent/Legal Guardian Signature*

Signature Name*

Date of Signature*

Date

Parent / Legal Guardian Consent Form