Children With Special Healthcare Needs Form Page 2
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2Sierra Vista Unified School District No. 68
Sierra Vista, Arizona 85635
HEALTH PROCEDURES CONSENT FORM
I understand that the school is permitted, but not required by law, to provide specialized physical health care
services to my child. Therefore, in consideration of the school agreeing to administer such treatment, I agree
to hold the school and its employees free from any and all responsibility for the results of such treatment or
the manner in which it is administered and to indemnify each of them against loss by reason of any civil
judgment arising out of these arrangements which may be rendered against them.
I agree to bring necessary equipment and supplies, labeled with proper directions, for use at the school.
I, the undersigned parent (or guardian) of _______________________________________________________
(Student’s full name)
request that treatment be administered to my child in accordance with the instructions of my physician,
_______________________________________, as indicated on the reverse of this form. Such treatment is to
be administered by a member of the school staff as designated by the director; I will notify the school
immediately if I change physician treatment. You are requested to continue such treatment until notified by
me or my physician to discontinue such treatment, and where such notice is given orally, it shall be confirmed
in writing within 24 hours. The school is authorized to secure emergency medical services for my child
whenever the need for such services is deemed necessary by the principal, school nurse, or designated staff
member.
I have reviewed the order for safe implementation. This order is good for this current school year.
Parent/Guardian Signature: ___________________________________________________________________
Address: __________________________________________________________________________________
Home Telephone: ____________________Work Telephone: _________________Cell: ___________________
I have reviewed the order for safe implementation.
School Nurse signature: _____________________________________________Date: ____________________
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