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Preventative Health Care Examinations Permission Form

Jefferson County Public Schools (JCPS) Health Services

Dear Parent or Guardian:

Our school is providing an opportunity for students to obtain a FREE preventative

health care examination and/or dental examination (if applicable). When

students participate in this free service, they will have completed the school

physical examination and/or dental examination that are required by Kentucky

State Law (704 KAR 4:020 and KRS 156.160). A physical exam must be

completed for students entering a Kentucky school for the first time and upon

entering sixth grade. The dental exam is required for students entering

kindergarten or first grade for the first time, and only includes those children who

are ages 5 and 6. The Louisville Metro Department of Public Health and

Wellness will only be conducting those dental exams that are scheduled via

Health Services.

You are welcome to be present during the examination, however it is not

necessary. Once the exam(s) are completed, a copy of that exam will be sent

home for your review. If the health care provider performing the exam feels that

it is necessary to contact you immediately, they will do so. It is the

parent/guardian’s responsibility to follow up with your child’s primary care

provider if you have any questions or concerns regarding the exam copy that was

sent home.

If you would like for your child to participate in this service, please complete the

information below, as well as the top portion and medical history on the attached,

state mandated Preventative Health Care Examination form and/or state

mandated dental form, and return it to school by _________________________.

School Name: ___________________________________________________

Child’s Name: ________________________ Date of Birth: ______________

Parent/Guardian’s Name: __________________________________________

Home Phone: _______________Cell: ______________Work: _____________

Emergency Contact: ________________________ Phone: _______________

I give permission for the JCPS Health Services Nurse Practitioners and/or the Louisville Metro

Department of Public Health & Wellness dental staff to provide my child with a preventative health

care examination at school. I agree to hold the Board, its employees and agents harmless from

and indemnify the Board against any claims, demands, action or judgments resulting from the

actions in receiving this service.

____________________________________

_____________________

Signature of Parent/Guardian

Date

Updated 8/24/2012

Preventative Health Care Examinations Permission Form - Jefferson County Public Schools (Jcps) Health Services