School District
#261
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Jerome Jt. School District #261
Policy Group
3000 Students
Jerome Joint School District No. 261
Notice of Health Services 3500F
Dear Parent or Guardian,
The purpose of this form and the attached copy of the District's policy on Student Health/Physical Screenings/Examinations is to provide notice of all health services offered or made available through the school by the District or by any private organizations and to provide notice of the District's policy on physical examinations and screening of students and to obtain parent/guardian consent for these services. The District may also provide health care services without parent/guardian consent if District staff reasonably determines that a medical emergency exists and:
Furnishing the health care service is necessary to prevent death or imminent, irreparable physical injury; or
District staff can't contact the parent/guardian despite a reasonably diligent effort and the student's life or health would be seriously endangered by further delay in the furnishing of health care services.
The District will provide the following additional health services or examinations which can only be provided with parental permission or in the event of an emergency as described above:
Health Service or Exam | Examples | Initial to Indicate Permission to Conduct the Health Service or Exam |
Preventative health and wellness services and screenings as described in Policy 3500 | Vision ScreeningHearing ScreeningDental ScreeningScoliosis ScreeningLice Checks | |
Administering or assisting of the administration of medication as described in Policy 3510 | Medication prescribed by a medical provider or over the counter that needs to be administered during school hours. |
First aid and emergency care as described in Policy 3540 | Vital SignsBand aidesBandagesIce PackEpi Pen-in an emergency | |
Appropriate management of all health conditions with parental consent | 504 Health Care Plan Individual Health Care Plan | |
Any health services the District deems appropriate |
Parent Emergency Contact Information:
Parent I : Emergency Contact Name:____________________________________________________________________
Emergency Contact Phone Number:___________________________________________________________
Emergency Contact Email Address:____________________________________________________________
Parent 2: Emergency Contact Name:____________________________________________________________________
Emergency Contact Phone Number:___________________________________________________________
Emergency Contact Email Address:____________________________________________________________
Please select one of the following options:
_____ I hereby designate the following emergency contact for my child and grant them authority to consent to health care services provided by the school in the school's absence of ability to reach me.
Emergency Contact Name:_________________________________________________________________________
Emergency Contact Phone Number:_________________________________________________________________
Emergency Contact Email Address:__________________________________________________________________
_____ I do NOT wish to designate an emergency contact to consent to health care services provided by the school in the school's absence of ability to reach me.
Student Name: _____________________________________________________________
Parent Signature: ___________________________________________ Date:___________