Student Name: Student Number:
SCHOOL HEALTH SERVICES
the School Health
Services Program. My child will receive emergency care in school, and
health appraisals including vision, hearing, growth and development.
If, upon administering a vision screening through the school or any other OCPS program, my child is determined to have a need for a follow-up
vision examination and if my child is eligible or otherwise financially qualified, I hereby authorize for OCPS or a designated third party to provide
a no-cost comprehensive vision examination by a licensed optometrist which may include dilation, refraction, and glasses if prescribed.
In the event of an EMERGENCY, I understand that the school will access the 911 emergency medical system immediately. To expedite care, I
give my permission for school personnel to provide
medical information to the responding emergency team to initiate treatment and transport to
an appropriate facility. I give my permission to first responders, medical personnel, and staff to initiate treatment immediately upon arrival. I
request to be notified of my child’s condition and admission as soon as possible. If I cannot be reached, I request that the admitting facility
notify one of the other persons listed above of my child’s condition and admission. I agree to be financially responsible for my child’s total
treatment and transport.
For child with IEP or receiving ESE related services, I authorize the School Board of Orange County, Florida
to release and exchange my child’s confidential information to agencies of the State of Florida which would
allow Orange County Public Schools to verify Medicaid eligibility, bill Medicaid for reimbursable Certified
School Match services reference on my child’s IEP and receive Medicaid reimbursement for Exceptional
Student Education (ESE) services it provides to my child while at school. I understand that my child will
continue to receive services referenced on his/her IEP whether or not I give consent. Please take the student's
Security card to the school Registrar to finalize
*The School Board of Orange County, Florida is authorized to collect social security numbers (“SSN”) of students as set forth in Sections 1008.386 and
119.071(5)(a)6, Florida Statutes.The provision of a student’s SSN on the enrollment form is optional and is not required as a condition for enrollment within the District.
Any SSN provided in connection with enrollment will only be used for research, reporting and recording purposes. The collectio
n of the SSN shall not be used for
immigration enforcement. Providing the student’s SSN to the School Board of Orange County, Florida for these purposes means that you consent to the use of the
student’s SSN in the manner described.
Florida Statute §837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official
duty shall be guilty of a misdemeanor of the second degree.
(This form is effective until the first day of next school year or one year from the date signed, whichever is later)
In the event of an incident or emergency and I cannot be reached, I consent and request additional contacts listed above be notified of my child’s
condition and/or of emergency medical services response to the incident.
By signing this form, I accept and acknowledge the terms herein.
OCPS Stu (Revised
01 12 2021) OCPS0486Pup