Health Care Services Consent Form

Health Care Services Consent Form
In accordance with Idaho Code 32-1015 and Policy 639 – Parental Rights in Education, it is the policy of the Preston School District to obtain parent/guardian consent for the provision of health care services to students under the age of 18, except where consent cannot be timely obtained in emergency situations. Health care service means a service for the diagnosis, screening, examination, prevention, treatment, cure, care, or relief of any physical or mental health condition, illness, injury, defect, or disease. In the school setting, health care services may include counseling; treatment of minor injuries or illnesses; first aid; vision, hearing, dental, or scoliosis screenings; immunizations; or crisis intervention. School health care services do not include any of the following: providing or performing an abortion; counseling in favor of abortion; referrals for abortion; or dispensing emergency contraception.

School nurses, school counselors, licensed health care professionals contracted with the district and, where appropriate, trained unlicensed staff, are authorized to furnish health care services. Questions regarding school health services should be directed to Amy Jensen, District Nurse.

Parents/guardians of students with chronic health conditions, food or other allergies, seizure disorders or epilepsy, asthma, diabetes, or G-tube which may require treatment or monitoring during the school day should contact the school nurse for development of a health care and/or medication administration plan.
Confidentiality and Student Health Records
All records containing student health information are the property of the district and protected under the Family Educational Rights and Privacy Act (FERPA). No other agency will have access to these records without your written consent. We protect the privacy of your child’s health information by:
- Limiting how we use and disclose health information.
- Providing physical safeguards (secure offices and storage facilities, electronic protections, and procedures).
- Training employees about privacy policies and procedures
Student Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Student Gender

MaleFemale
Student School*

Pioneer ElementaryOakwood Elementary SchoolPreston Junior HighPreston High SchoolFranklin County High School
Student Grade*
Teacher's Name*
Parent/Guardian #1 *
Parent/Guardian #2
Emergency Contact (other than Parent/Guardian) *
My child has the following life-threatening condition(s) that may need emergency treatment or medication (EpiPen, glucagon, emergency seizure medications, asthma inhaler, etc.) at school (check all that apply:*

NoneAsthmaDiabetesFood allergiesSeizuresOther
For all food or other allergies, please specify the allergy and typical reaction:
Child’s Other Medical History: Please specify important medical information staff for which staff should be aware (e.g. heart condition, cancer/blood disorders, behavior/emotional, G-tube, etc.):
Medications taken every day:
Please check the areas in which you would like to pre-authorize Preston School District to provide services, if available at the school:

Adhesive bandages (Band Aid)Ice packFeminine hygiene productsScreenings (lice, hearing, vision)Counseling services for emotional and mental health related issuesFull consent for all health care services including physical or mental health conditionsOther
I authorize the school nurse to give my child over-the-counter medications that I provide along with the Medication Administration Form located on the district website under "District Information - Parents and Students"

YESNO
Health Care
Dental Care
Please Read Carefully
Name of person signing*

First NameLast Name
Email*
example@example.com
Today's Date*

MonthDayYear
Date
I understand and acknowledge that this consent is valid until revoked by me in writing. Signature*

Clear
Should be Empty:

Health Care Services Consent Form

Confidentiality and Student Health Records

Please Read Carefully