• 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 Information

Student Name(Required)
MM slash DD slash YYYY

Parent/Guardian Information

MM slash DD slash YYYY