Stone Bridge Middle School

Discovering True North

Dear Parent/Guardian:

As per FERPA (Family Educational Rights Privacy Act), written consent must be obtained to release health information to individuals involved in your child's care outside of the school health service department. Individuals receiving information about your child's health issue may include but are not limited to the following: teacher, instructional assistant, administrtor, school bus drive, lunch aide, etc. Your Childs's health information will only be shared on a need to know basis.

Student's First Name

Student's Last Name

Grade

Parent's Name

Consent Option

I GIVE CONSENT to share my child's health information when necessary to provide optimal care while in school.

I DO NOT GIVE CONSENT to share my child's health information when necessary to provide optimal care while in school.

Please sign and return this form immediately upon receipt.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.