Medical Consent Optout - Compass Public Charter School

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PURPOSE

Because the language in Senate Bill 1329 dealing with Parent Rights is unclear regarding the school’s ability to provide minor medical care for students, this form is intended to inform parents of the type of minor medical care we provide in the event of minor injury or illness. The school will always attempt to contact parents in the case of serious injury or illness. The list of minor medical treatments below is not exhaustive but rather lists examples of typical treatment. If you do not want your student to receive any medical care, even for minor injuries/illness, without your consent, please submit the opt-out form below.

Parent/ Guardian Full Name

First

Last

Parent/Guardian Email Address

Parent/Guardian Phone Number

Parent/ Information Name

Student Information

Fill out one form per student.

Student Full Name

First

Last

Student Grade Level

Date of Birth

Examples of care:

K-3 annual hearing screenings;
application of band-aids with antibiotic cream for minor scrapes;
ice packs for bumps & bruises;
eye drops for contacts/dry eye;
care for bee stings;
anti-itch cream for rashes;
gauze to stop nose bleeds;
counselor check-in for conflict resolution and/or emotional support.

Our standard practice is to always contact parents for eye injuries, head injuries, vomiting, and fever.

Opt-Out for Minor Medical Care

I, the undersigned parent/guardian, do not authorize school personnel to provide minor medical treatment to my child without consent specific to each instance.

I Opt Out - I understand that school personnel will call me for any and every instance where my child might need medical care including the examples above.

Signature

Clear Signature

Date