School-Based Health Program Short Form

I understand that my consent is required by Southeast Mississippi Rural Health Initiative (SEMRHI), before my child can receive services. I authorize the designated health care professionals to provide necessary and/or advisable assessment for the below-named student. I understand that medical services are billed to insurance for payment, and 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 SEMRHI.
By completing this Student Health History form, I acknowledge that participation in the program is voluntary and does not replace regular care; and, my child will receive health services from SEMRHI during the current school year, from July 1 through June 30. I understand this authorization must be renewed with a new registration and signature each school year. Services are expected to continue until they graduate, withdraw from school, or transfer to another school district. At any time, I can opt-out of the program by contacting SEMRHI at 601-658-0058.