Health Services Forms for Parents and Guardians

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Caregiver Consent for Child COVID-19 Symptomatic Testing Parent/Guardian Authorization of Another Adult for Administration of Medication Parent/Guardian Opt-Out for BMI Reporting Standard Authorization for the Exchange of Health Information

 

Caregiver Consent for Child COVID-19 Symptomatic Testing The Ithaca City School District offers symptomatic testing 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

   

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