School-Based Health Program Short Form

I understand that my consent is required by Southeast Mississippi Rural Health Initiative, before my child can receive services. I hereby provide consent for the below-named student to receive health care services and screenings for vision, hearing, scoliosis, behavioral health, mental health, and general aid at no cost to the parents of the School District. I authorize the designated health care professionals to provide necessary and/or advisable assessment for the below-named student. Medical services are billed to insurance for payment. Any remaining balance is covered by the SEMRHI’s school-based health program. I give permission for necessary medical tests and treatments. I further release and hold harmless my child’s School District and do give, grant, and release from any liability, costs, or loss which my child or I may sustain or incur now, or at any time in the future or as a direct or indirect result of any treatment, consultation or other action or inaction by the Southeast Mississippi Rural Health Initiative.
By completing this school-based health program short form, I acknowledge that my child will receive health services from Southeast Mississippi Rural Health Initiative, Inc. until they graduate, withdraw from school, or transfer to another school district. I have previously completed a long student health history form and am updating annual recorded information. At any time, I can opt-out of the program by contacting Southeast Mississippi Rural Health Initiative, Inc. at 601-545-8700.