Health Services Forms for Parents and Guardians

Caregiver Consent for Child COVID-19 Symptomatic Testing

The Ithaca City School District will conduct a COVID-19 symptomatic testing program throughout the 2021-2022 academic year for students who become unwell at school. Student participation in the testing program is voluntary, and the Ithaca City School District is requesting that parents/caregivers complete a consent form to allow their children to be tested for COVID-19 at school. We will not test your child without your consent.

• Caregiver Consent for Child COVID-19 Symptomatic Testing Form

Translated Consent Forms

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Non-In-Person Learning Application/COVID-19 Health Eligibility

Students with health concerns related to COVID-19 - whether a contraindication to COVID-19 vaccination (conditions that increase the risk for a serious adverse reaction) or a health condition that places the student at greater risk of severe illness from COVID-19 as outlined by the Centers for Disease Control (CDC) - and who have supporting medical documentation via the COVID-19 Health Eligibility Form are eligible for non-in-person learning for 2021-22.

To apply for non-in-person learning, parents/guardians should complete the following forms:

1. Application for Non-In-Person Learning

2. COVID-19 Health Eligibility Form

All required documentation must be submitted by August 26, 2021. Applications submitted after this deadline (for example, if a student has a newly developed medical condition) will be considered on a case-by-case basis.

All applications will be reviewed by an ICSD-appointed committee of healthcare professionals.

Parent/Guardian Authorization of Another Adult for Administration of Medication

Through this form, parents/guardians can authorize another adult (such as a friend, family member, or household member) to administer certain medications to their child.

• Parent/Guardian Authorization of Another Adult for Administration of Medication Form

Parent/Guardian Opt-Out for BMI Reporting

By completing this form, parents/guardians can opt out of having their children's weight status information included in the 2022-2023 School Survey by the New York State Department of Health.

• Parent/Guardian Opt-Out for BMI Reporting Form

Standard Authorization for the Exchange of Health Information

This form authorizes the exchange of protected health information (PHI) and education records (including personally identifiable information obtained therefrom) between your child’s health care provider and authorized school officials.

• Standard Authorization for the Exchange of Health Information Form