PARENT/GUARDIAN CONSENT FORM

7900 N Hwy 7 I Jessieville, AR 71949 Phone Number: 501-984-4210

Student Name

DOB

Grade

Address (Street, Apt., City, State, Zip)

Phone

Format: (000) 000-0000.

Alt. Phone

Format: (000) 000-0000.

Current Primary Care Physician

Last Child Wellness Visit to PCP

Allergies

I understand that the following types of services are being offered through Jessieville School District's School Based Health Clinic by the following providers and GIVE MY

CONSENT FOR TREATMENT WHERE NOTED BY MY INITIALS.

Physical Health Services provided by CHI St. Vincent. Services

Physical Health Services provided by CHI St. Vincent. Services to

include, but are not limited to:

Routine Physical Examinations, including sports physicals

Diagnosis and Treatment of Acute and Chronic Illness Treatment of Minor Injuries Laboratory Tests Health Education, Counseling, and Wellness Promotions Nutrition Education and Weight Management Prescription Medication

Referrals for services not provided Random Drug Testing for Extra Curriculars

Behavioral Health Services provided by Life Strategies Counseling Inc.

Transportation Consent/give my permission for the school to transport my child to Lions Health and Wellness located on the Jessieville School District Campus from other Jessieville School District Buildings.

Transportation Consent/give my permission for the school to transport Lions Health and Wellness located the School District

By signing below, I give my permission for the student listed above to receive treatment, as noted by my initials, through Jessieville School Districts School Based Health Center (Lions Health and Wellness) by the above providers.

Parent/Guardian Signature

Date

*Signed form remains valid while a student is enrolled in Jessieville School District, or until rescinded in writing. If any important information changes during the school year (address, insurance coverage, phone number) a new form will be needed. Forms will be issued yearly in order to stay up to date.