School-Based Health Program Short Form – Southeast MS Rural Health

SEMRHI School-Based Health Program Short Form

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School District
School District(Required)

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 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.(Required)
I agree to the privacy policy.
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 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.
Student's Name(Required)
First Middle Last
Student's Birthdate(Required)
MM slash DD slash YYYY
School(Required)
Grade
Sex(Required)
- Male
- Female
Social Security #(Required)
Email Address(Required)
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Work Phone

Is Student the Dependent of A Migrant Worker:(Required)
How many people live in your household?
What is your annual household income!
The above household information is used to establish funding programs for low-income households.
Has anything changed related to your child's health that you think is important for us to know?
The above named student has the following health care insurance coverage:
Insurance Name(Required)
Health Insurance ID #
Policy Holder Name (if not student)
First Middle Last
Date of Birth
MM slash DD slash YYYY
Insurance ID #
Group #
3. Please check here if you do not have any HEALTH insurance that covers the student?
- My health insurance DOES NOT cover the student.
Parent/Guardian Signature(Required)
Date(Required)
MM slash DD slash YYYY
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SEMRHI School-Based Health Program Short Form

Step 1 of 3

School District