Parent/Guardian Consent for School Health Services

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Date Submitted

This consent will remain in effect until your child transfers to another school district, graduates or you indicate in writing that you wish to rescind this consent for school health services.
When necessary, emergency health services such as first aid, cardiopulmonary resuscitation (CPR) or use of an automated external defibrillator (AED) will be performed until emergency medical services arrive on campus.
Separate parent/guardian authorizations will be required for school clinic staff or school staff to administer daily or as-needed prescribed or over-the-counter medications, conduct medical procedures or provide medical treatment.

Student Name(Required)

First Middle Last

Sex(Required)

Male

Female

Date of Birth(Required)

Address(Required)

Dirección de la calle Dirección de la calle 2 Ciudad State / Province / Region ZIP / Postal Code Country

Name(Required)

First Middle Last

Email(Required)

Relationship to Student(Required)

Date of Birth(Required)

Cell Phone(Required)

Work Phone

Address

Dirección de la calle Dirección de la calle 2 Ciudad State / Province / Region ZIP / Postal Code Country

Parent/Guardian Signature(Required)