Healthy Children, Better Students, Thriving Communities.

Dear Parent or Guardian:

I have identified that your child, ______, has the following health care need/s ______. Your child may be eligible to receive FREE health care services from Healthy Learners, a faith based non-profit organization that connects children to care so that poor health is not an obstacle to doing well in school.

Healthy Learners can assist with the following services:

  • Assistance with Medicaid Application Process
  • Assistance with referrals for Clinical Counseling
  • Coordination of Health Care
  • Dental care
  • Hearing Evaluations and Care
  • Medications
  • Transportation to Appointments
  • Treatment for Medical Needs
  • Vision Care

Healthy Learners can serve any student I refer who meets program eligibility requirements. Once a student is determined eligible for services, Healthy Learnerswill schedule your child’s appointment(s) and will notify me. I will then inform you of the date, time and location of the appointment. Healthy Learners can also pick up your child from school and take him/her to their appointment during the school day so that you do not have to miss any work if you give permission. Once the appointment is completed, the Healthy Learners staff member will return your child to school, inform me of the appointment results and I will share the results with you.

If you would like me to refer your child to Healthy Learners, please complete (in pen) the attached paperwork,signand returnto me as soon as possible so I can further determine your child’s eligibility for Healthy Learners services. Your child cannot receive health care without your permission. Healthy Learnersmust receive your child’s completed paperwork before services can begin. Please feel free to contact me at school if you have any questions. Healthy Learners can also be contacted directly at ______.

Thank you,

School Nurse

HEALTHY LEARNERS

SCHOOL YEAR 2016-2017

PAGE 1 OF 3

Student Information and Health History

HEALTHY LEARNERS

PAGE 2 OF 3

Permissions And Release From Liability

Permission to Provide Services and To Participate In Program evaluation

I give permission to Healthy Learners to provide services during the _2016-2017_ school year to my child. These services may include a professional medical evaluation and treatment as well as transportation of my child to and from school to their medical appointments and other services. I understand that theinformation I provide on page one may be shared withthe health care provider(s)who partner with Healthy Learners in order to assess, evaluate and treatmy child’s health care needs. I understand and consent to this exchange of health information between Healthy Learners and the health care providers.I understand that my child’s participation is voluntary.

I also understand as part of Healthy Learners services, Healthy Learners collects information about children served to measure the benefit and impact of the program, for program planning purposes, and toobtain and maintain grant funding in order to continue providing services to children at no cost to families. All information obtained will be kept confidential. Evaluation reports for publication are made available to the public and contain only information that is summarized or grouped together and does not use any names or identifying information. I understand if I do not wish formy child to be included in Healthy Learners program evaluation measures, I should submit a signed, written letter to Healthy Learners at 2749 Laurel Street, Columbia, SC 29204.I understand that my child may be asked to participate in a survey to assist with program evaluation.

I also understand Healthy Learners utilizes opportunities to promote the Healthy Learners program for the purposes of marketing, development (fundraising), public relations and promotion to educate others about the program. This may include photographs, audio or video image recording. Children are identified only by first name or initials.

Permission to Transport

Yes - I choose to have the Healthy Learners staff transport my child to appointments from school.

No - I will provide my child’s transportation to appointments.Best day of weekfor appointments? ______

Permission to Photograph, Audiotape, or Video (To Use Name and Likeness)

Yes No I give my permission to photograph, audiotape or video/record my child’s image and/or voice, touse name andlikeness for promotional/educational purposes.

Permission to Access School Data

I give Georgetown County School Districtpermission to give Healthy Learners allof my child’s school data, including attendance, grades, discipline, testing scores and standardized testing results for the purpose of tracking the impact and success of the Healthy Learners program. I authorize Healthy Learners to request, receive and use the information received for all years of my child’s enrollment in the above school district in order to establish a before and after baseline in tracking the impact of my child having received Healthy Learners services.

I understand that I may ask for a copy of any of my child’s records that Healthy Learners has received from the above school district. I also give permission to Healthy Learners to share my child’s school data with its supporters and donors for the purpose of tracking the impact and success of the Healthy Learners program. No identifying information (names) will be released. I understand that those supporters and donors cannot release this information to anybody else without my written consent.

Release From Liability

I, on behalf of myself, my child, ______, and my heirs hereby

(Child’s Name: First – Middle – Last)

RELEASE AND HOLD HARMLESS HEALTHY LEARNERS FOR ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF HEALTHY LEARNERS, its donors, sponsors, board members, employees and agents OR OTHERWISE, except in the case of gross negligence and/or intentional misconduct. I HAVE READ THE ABOVE PERMISSIONS AND RELEASE FROM LIABILITY, UNDERSTANDING ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP CERTAIN RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY PROMISES OR THREATS.

______

Parent or Legal Guardian’s Signature Relationship to Child Date

HEALTHY LEARNERS

PAGE 3 OF 3

Permission to Use or Release Protected Health Information

I authorize Healthy Learners to request, receive, use, and disclose information relating to my child’s,

______, medical case from the patient information department at

(Child’s Name: First – Middle – Last)

______TidelandsGeorgetown Memorial Hospital______.
(Applicable Health Care Provider’s Name)

I UNDERSTAND THE FOLLOWING:

  • Information Requested: Dates my child visited the emergency room, reason for emergency room visit/s, diagnosis, payment method/insurance, and the cost of each visit.
  • Purpose for Request: To track the outcomes of the Healthy Learners program in order to better serve the health needs of students participating in the program.
  • Expiration of this Permission form: This permission will expire when my child no longer receives services from the Healthy Learners program.
  • Right to Withdraw this Permission:
  • I may withdraw this permission at any time. If I do withdraw this permission, I understand that Healthy Learners may have already used or released information about my child before I withdrew this permission.
  • To withdraw this permission I understand that I must deliver a signed, written letter clearly stating that I withdraw this permission to:
  • This Permission is Not Linked to Participation in Healthy Learners: If I do not sign this permission, it will not affect any of the services Healthy Learners will provide to my child, including medical treatment, payment for services, enrollment in a health plan or eligibility benefits if applicable.
  • Information Requested May be Subject to Further Release: Any information Healthy Learners receives about my child may be given to somebody else and that information may no longer be protected by law. No identifying information (names) will be released.

______

Parent or Legal Guardian’s Signature Relationship to ChildDate