Please read the attached Welcome Letter and Notice of Privacy Practices. You may print a copy of this for your records. NOTE: Please complete the following registration. Please DO NOT "X" out at any time -- this will create an incomplete response and we will not be able to register your student.
Parent/Legal Guardian of Student (please type your name -- First & Last)* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Student's Last Name* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Student's First Name* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Student's Middle Initial (optional)
Student's Date of Birth* must provide value
Today M-D-Y
Student ID #
Street Address:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
City:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
State:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Zip Code:* must provide value
I, ______ , give my consent for ______ ______ , DOB ______ , who resides at ______ , ______ , ______ , ______ , to receive health services at the Christiana School-Based Health Center (SBHC) administered by Christiana Care. SERVICES PROVIDED BY THE SCHOOL-BASED HEALTH CENTER INCLUDE: *Please be aware: In accordance with Delaware law, any minor age 14 or over may consent to voluntary outpatient mental health services and parental consent is not required. ELECTIVE SERVICES: I wish for my child to receive the above-listed elective services * must provide value
Yes
No
CONTRACEPTIVE IMPLANT (NEXPLANON) -- FEMALES ONLY My child may receive Nexplanon * must provide value
Yes
No
THE SCHOOL-BASED HEALTH CENTER DOES NOT PROVIDE THE FOLLOWING SERVICES: CONFIDENTIALITY TELEHEALTH CONFIDENTIALITY CONTINUED My child and I have read this form carefully. All my questions have been answered to my satisfaction. I understand that I may call the School-Based Health Center Coordinator if I have any questions before or after I sign this consent for services.(Please click on the green plus sign to the right of the page to add your signature.) * must provide value
Parent/Legal Guardian Date/Time Signed:* must provide value
Now M-D-Y H:M
STUDENT SIGNATURE
Student Date/Time Signed: Now M-D-Y H:M
COMMUNITY HEALTH WORKER (CHW) PROGRAM AGREEMENT______ ______ , navigate the healthcare PATIENT ACKNOWLEDGEMENT* must provide value
Student Date/Time Signed: Now M-D-Y H:M
PARENT SIGNATURE
Parent Date/Time Signed: Now M-D-Y H:M
APPOINTMENT OF DECISION MAKER FOR MINOR______ , the ________________________ of this child, appoint the following to be a decision maker(s) for my child ______ ______ in my absence: Mother
Father
Legal Guardian
Name of Decision Maker please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Relationship to Minor Child please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
I authorize the above decision maker to give consent for treatment of the following: Routine health maintenance (physical exams)
Immunizations (sign consent for shots)
Medical care for illness
X-rays and laboratory tests
Are there additional Decision Makers you'd like to appoint?* must provide value
Yes
No
Name of Decision Maker please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Relationship to Minor Child please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
I authorize the above decision maker to give consent for treatment of the following: Routine health maintenance (physical exams)
Immunizations (sign consent for shots)
Medical care for illness
X-rays and laboratory tests
Are there additional Decision Makers you'd like to appoint?* must provide value
Yes
No
Name of Decision Maker please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Relationship to Minor Child please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
I authorize the above decision maker to give consent for treatment of the following: Routine health maintenance (physical exams)
Immunizations (sign consent for shots)
Medical care for illness
X-rays and laboratory tests
Are there additional Decision Makers you'd like to appoint?* must provide value
Yes
No
Name of Decision Maker please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Relationship to Minor Child please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
I authorize the above decision maker to give consent for treatment of the following: Routine health maintenance (physical exams)
Immunizations (sign consent for shots)
Medical care for illness
X-rays and laboratory tests
Are there additional Decision Makers you'd like to appoint?* must provide value
Yes
No
Name of Decision Maker please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Relationship to Minor Child please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
I authorize the above decision maker to give consent for treatment of the following: Routine health maintenance (physical exams)
Immunizations (sign consent for shots)
Medical care for illness
X-rays and laboratory tests
I am authorizing the person(s) named above to bring my child for medical care and treatment. This appointment of alternate decision maker expires on: ______ /______ /______ or the child's 18th birthday. To cancel this appointment of the decision maker, please provide this office with written notification. Today M-D-Y
PARENT SIGNATURE
Relationship to Patient please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Parent Date/Time Signed: Now M-D-Y H:M
WITNESS SIGNATURE
Print Name or ID# please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Witness Date/Time Signed: Now M-D-Y H:M
Student's Grade* must provide value
9
10
11
12
Student's Name: ______ , ______ ______ Preferred First Name: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Nickname: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Birth Sex* must provide value
Male
Female
Preferred Language* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Gender Identity:* must provide value
Male/man/boy
Female/woman/girl
Transgender Male/man/boy
Transgender Female/woman/girl
Nonbinary, genderqueer, or not exclusively male or female
Prefer not to answer
Pronouns:* must provide value
He/Him/His
She/Her/Hers
They/Them/Theirs
No Pronouns
Declines to Specify
Other (please specify)
Please specify "Other" pronoun:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Student's Address: ______ , ______ , ______ , ______ Student's DOB: ______ Race (mark all that apply):* must provide value
Caucasian/White
Black/African American
Asian/Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
Undetermined
Other
Please specify "Other" race: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Ethnicity * must provide value
Hispanic/Latino
Arabic
Non-Hispanic/Latino/Arabic
Other
Please specify "Other" ethnicity: please do not apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Primary Care Physician (Family Doctor) Name: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Primary Care Physician Phone Number: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Preferred Pharmacy Name: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Preferred Pharmacy Phone Number:
Student's Cell Phone #: please enter as xxx xxx xxxx with no dashes or parentheses
Is student employed: Yes
No
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Emergency Contact Relationship to Student: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Emergency Contact Phone #: please enter as xxx xxx xxxx with no dashes or parentheses
PARENTAL/LEGAL GUARDIAN INFORMATION
Are you the student's:* must provide value
Mother
Father
Legal Guardian
Mother's Full Legal Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Mother's Date of Birth: Today M-D-Y
Mother's Street Address, City, State, Zip Code:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Mother's Email Address:please do not use apostrophes (') in your answer as this may cause an error* must provide value
please enter NA if there is no email address
Best Way to Contact Mother:* must provide value
Home Phone
Cell Phone
Work Phone
Mother's Home Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Mother's Cell Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Mother's Work Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Mother's Employer Name & Address: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Father's Full Legal Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Father's Date of Birth: Today M-D-Y
Father's Email Address:please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead* must provide value
please enter NA if there is no email address
Father's Street Address, City, State, Zip Code:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Best Way to Contact Father:* must provide value
Home Phone
Cell Phone
Work Phone
Father's Home Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Father's Cell Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Father's Work Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Father's Employer Name & Address: please do not use apostrophes (') in your answer as this may cause an error
Legal Guardian Name (if not mother or father):* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Relationship to Student:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Legal Guardian's Date of Birth: Today M-D-Y
Legal Guardian's Street Address, City, State, Zip Code:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Guardian's Email Address:please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead* must provide value
please enter NA if there is no email address
Best Way to Contact Guardian:* must provide value
Home Phone
Cell Phone
Work Phone
Guardian's Home Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Guardian's Cell Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Guardian's Work Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Guardian's Employer Name & Address: please do not use apostrophes (') in your answer as this may cause an error
INSURANCE INFORMATION (REQUIRED) -- Please complete this information and if you have insurance, please upload a copy FRONT and BACK of your insurance card where prompted below:
What is the primary source of payment for care -- please check one:* must provide value
No Insurance (if you need assistance with obtaining insurance, please contact the SBHC)
Medicaid Provider
Commercial Insurance
Delaware Healthy Children Program
Medicaid Provider Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Medicaid Number:* must provide value
Medicaid Insurance Card -- please upload a copy of the FRONT of your insurance card
Medicaid Insurance Card -- please upload a copy of the BACK of your insurance card
Commercial Insurance Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Commercial Insurance Policy Number:* must provide value
Commercial Insurance Subscriber Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Commercial Insurance Relationship to Student:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Commercial Insurance Subscriber Date of Birth:* must provide value
Today M-D-Y
Commercial Insurance Card -- please upload a copy of the FRONT of your insurance card
Commercial Insurance Card -- please upload a copy of the BACK of your insurance card
What is the secondary insurance information if applicable? Medicaid Provider
Commercial Insurance
Medicaid Provider Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Medicaid Number:* must provide value
Medicaid Insurance Card -- please upload a copy of the FRONT of your insurance card
Medicaid Insurance Card -- please upload a copy of the BACK of your insurance card
Commercial Insurance Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Commercial Insurance Policy Number:* must provide value
Commercial Insurance Subscriber Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Commercial Insurance Relationship to Student* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Commercial Insurance Subscriber Date of Birth:* must provide value
Today M-D-Y
Commercial Insurance Card -- please upload a copy of the FRONT of your insurance card
Commercial Insurance Card -- please upload a copy of the BACK of your insurance card
PARENT SIGNATURE* must provide value
Print Name:* must provide value
please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Relationship to Student please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Parent Date/Time Signed: Now M-D-Y H:M
A complete and accurate health history is needed so that Center staff can provide high quality care. Please complete this form as much as possible.______ , ______ ______ ______ ______ Does your child have any allergies? (food, medication, latex)* must provide value
Yes
No
If "Yes", please list:* must provide value
please do not apostrophes (') in your answer as this may cause an error
Please provide the following information about medications your child is taking: How many medications does your child take?* must provide value
1
2
3
4
5
More than 5
None
Name of first medication please do not use apostrophes (') in your answer as this may cause an error
Reason for taking the first medication please do not use apostrophes (') in your answer as this may cause an error
Start date for the first medication Today M-D-Y
Name of second medication please do not use apostrophes (') in your answer as this may cause an error
Reason for taking the second medication please do not use apostrophes (') in your answer as this may cause an error
Start date for the second medication Today M-D-Y
Name of third medication please do not use apostrophes (') in your answer as this may cause an error
Reason for taking the third medication please do not use apostrophes (') in your answer as this may cause an error
Start date for the third medication Today M-D-Y
Name of fourth medication please do not use apostrophes (') in your answer as this may cause an error
Reason for taking the fourth medication please do not use apostrophes (') in your answer as this may cause an error
Start date for the fourth medication Today M-D-Y
Name of fifth medication please do not use apostrophes (') in your answer as this may cause an error
Reason for taking the fifth medication please do not use apostrophes (') in your answer as this may cause an error
Start date for the fifth medication Today M-D-Y
Please list the names of each medication, reason for taking, and start date for each: please do not use apostrophes (') in your answer as this may cause an error
Please check which of the following your CHILD has ever had:* must provide value
Acne/Skin Problems
ADHD/Learning Disability
Anemia
Anxiety
Arthritis
Asthma
Cancer
Chicken Pox
Cystic Fibrosis
Diabetes
Depression
Fainting Spells
Frequent Colds
Headaches
Head Injury
Heart Disease
Heart Murmur
Hemophilia
Hepatitis
High Blood Pressure
High Cholesterol
Kidney/Bladder Disease
Pregnancy/Childbirth/Miscarriage
Rheumatic Heart Disease
Scoliosis
Seasonal Allergies
Seizures
Sickle Cell
Sleeping Problems
Sports Injury
Stomach/Intestinal Problems
Suicide Attempts
Suicidal Thoughts
Substance Abuse
Thyroid Disease
Tuberculosis
None
Please provide more detail of your 'checked' selections above: please do not use apostrophes (') in your answer as this may cause an error
Has your child ever been hospitalized?* must provide value
Yes
No
If "Yes", please state the reason for hospitalization:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
If "Yes", when and where was your child hospitalized?* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Has your child ever received counseling for emotional health?* must provide value
Yes
No
If "Yes", what was the reason for counseling:* must provide value
please do not use apostrophes (') in your answer as this may cause an error
If "Yes", when and where did your child receive counseling?* must provide value
please do not use apostrophes (') in your answer as this may cause an error
Please check any of the following illnesses that your FAMILY MEMBERS (parent, brother, sister, grandparent, aunt, uncle, etc.) have ever had: ADHD/Learning Disability
Alcoholism/Drug Abuse
Anemia
Arthritis
Asthma
Birth Defects
Cancer
Cystic Fibrosis
Deafness
Diabetes
Headaches
Heart Disease
Hemophilia
Hepatitis
High Blood Pressure
High Cholesterol
Kidney/Bladder Disease
Mental Illness
Obesity
Seizures
Sickle Cell
Stroke
Thyroid Disease
Tuberculosis
Unexplained Death
Other
If "ADHD/Learning Disability", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Alcoholism/Drug Abuse", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Anemia", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Arthritis", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Asthma", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Birth Defect", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Cancer", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Cystic Fibrosis", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Deafness", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Diabetes", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Headaches", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Heart Disease", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Hemophilia", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Hepatitis", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "High Blood Pressure", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "High Cholesterol", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Kidney/Bladder Disease", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Mental Illness", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Obesity", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Seizures", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Sickle Cell", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Stroke", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Thyroid Disease", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Tuberculosis", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Unexplained Death", which FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
If "Other", please specify type of illness and FAMILY MEMBER: please do not use apostrophes (') in your answer as this may cause an error
PARENT SIGNATURE
Print Name: please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Relationship to Student please do not use apostrophes (') in your answer as this may cause an error - if needed, use a space instead
Parent Date/Time Signed: Now M-D-Y H:M
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