WHAT IS DASH?

The Colonial School District strives to help students be physically and emotionally well so they can be academically well. To reach this goal, Colonial is partnering with Nemours Children’s Health System (Nemours) and the Delaware Health Information Network (DHIN) on a project to support our students’ health and attendance in school.

Through this project, the Data Access for Student Health or DASH, parents or guardians can give permission to Colonial to securely share attendance information and if the student has an IEP or 504 plan with their doctor(s), nurse(s), and medical office staff. This information will help the healthcare professionals work with families to provide outreach and medical attention to children who are missing school and may not be aware of potential services available.

How old is your student?

DASH Project Consent

(for students under age 18)

Health is important to success in school. Your child’s school is partnering with local doctors and nurses through the Data Access for Student Health (DASH) Project to help keep students healthy and successful at school. Please complete the form below to give consent for your child to participate.

By signing below, I give permission to participate in the DASH Project and I give consent to my school or others at Colonial to share and discuss my attendance records, IEP status, and 504 plan status with my care team, contractors who assist in the treatment and care coordination of me, and with any DASH project participant. I also give my doctor, nurse, and medical office staff permission to discuss pertinent medical and/or social needs with Colonial staff. This will allow Colonial to work with these healthcare professionals to keep me healthy and successful at school.

I acknowledge and understand that I have the opportunity to review the records to be shared and the right to challenge the contents of such records, and I certify that I am at least eighteen (18) years of age.

This consent will continue through my enrollment at Colonial unless I withdraw my consent in writing. I can withdraw my consent at any time. NOTE: If Colonial wishes to share or discuss other parts of my academic record with my medical team, I will be asked to provide separate consent.

By signing below, I give permission for my child to participate in the DASH Project and I give consent to my child’s school or others at Colonial to share and discuss my child’s attendance records, IEP status and 504 plan status with my child’s care team, contractors who assist in the treatment and care coordination of my child, and with any DASH project participant. I also give my child’s doctor, nurse, and medical office staff permission to discuss pertinent medical and/or social needs with Colonial staff. This will allow Colonial to work with these healthcare professionals to keep my child healthy and successful at school.

I acknowledge and understand that I have the opportunity to review the records to be shared and the right to challenge the contents of such records, and I certify that my child is less than eighteen (18) years of age.

This consent will continue through my child’s enrollment at Colonial unless I withdraw my consent in writing. I can withdraw my consent at any time. NOTE: If Colonial wishes to share or discuss other parts of my child’s academic record with my child’s medical team, I will be asked to provide separate consent.

DASH Project Consent

(for students at least age 18)

Health is important to success in school. Your school is partnering with local doctors and nurses through the Data Access for Student Health (DASH) Project to help keep students healthy and successful at school. Please complete the form below to give consent to participate.

By signing below, I give permission to participate in the DASH Project and I give consent to my school or others at Colonial to share and discuss my attendance records, IEP status, and 504 plan status with my care team, contractors who assist in the treatment and care coordination of me, and with any DASH project participant. I also give my doctor, nurse, and medical office staff permission to discuss pertinent medical and/or social needs with Colonial staff. This will allow Colonial to work with these healthcare professionals to keep me healthy and successful at school.

I acknowledge and understand that I have the opportunity to review the records to be shared and the right to challenge the contents of such records, and I certify that I am at least eighteen (18) years of age.

This consent will continue through my enrollment at Colonial unless I withdraw my consent in writing. I can withdraw my consent at any time. NOTE: If Colonial wishes to share or discuss other parts of my academic record with my medical team, I will be asked to provide separate consent.

By signing below, I give permission for my child to participate in the DASH Project and I give consent to my child’s school or others at Colonial to share and discuss my child’s attendance records, IEP status and 504 plan status with my child’s care team, contractors who assist in the treatment and care coordination of my child, and with any DASH project participant. I also give my child’s doctor, nurse, and medical office staff permission to discuss pertinent medical and/or social needs with Colonial staff. This will allow Colonial to work with these healthcare professionals to keep my child healthy and successful at school.

I acknowledge and understand that I have the opportunity to review the records to be shared and the right to challenge the contents of such records, and I certify that my child is less than eighteen (18) years of age.

This consent will continue through my child’s enrollment at Colonial unless I withdraw my consent in writing. I can withdraw my consent at any time. NOTE: If Colonial wishes to share or discuss other parts of my child’s academic record with my child’s medical team, I will be asked to provide separate consent.

Student Name

First NameLast Name

Student Date of Birth

Date

Parent/Guardian Signature

Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Mobile Number

Please enter a valid phone number.Format: (000) 000-0000.

Student Primary Care Practice is connected to:

Other

Dash Project Consent Form

DASH Project Consent

(for students under age 18)

DASH Project Consent

(for students at least age 18)