Student Name
*
First Name
Last Name
Preferred Name
School Name
*
Date of Birth
*
MM
DD
YYYY
Race
*
Black or African American
Asian
White
American Indian and Alaska Native
Native Hawaiian or Pacific Islander
Multiracial
Other
Prefer not to answer
Ethnicity
*
Hispanic/Latino
Non Hispanic/Latino
Sex Assigned at Birth
Male
Female
Gender
*
Male
Female
Transgender/ Non-Binary
Prefer Not to Disclose
Sexual Identity
*
Heterosexual (straight)
Lesbian
Gay
Bisexual
Pansexual
Asexual
Prefer not to answer
Other
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
*
Not required to be a parent or guardian
First Name
Last Name
Relationship to Emergency Contact
*
Parent/Legal Guardian
Sibling
Spouse/Partner
Child
Grandparent
Aunt/Uncle
Cousin
Friend
Neighbor
Colleague
Mentor
Other Family Member
Caregiver
Coach/Teacher
School Nurse/Therapist
Other
If other, please specify in the field below:
Emergency Phone
*
(###)
###
####
Services Offered
*
I agree to the following services (Check all that apply):
Annual Household Income
*
$0-$20,000
$20,001-$40,000
$40,001-$65,000
Greater than $65,001
Prefer not to answer
Insurance Carrier (if applicable)
Insurance Policy Phone Number
(###)
###
####
Name of Policy Holder
First Name
Last Name
Insurance Group ID
Insurance Policy Number
Name of Parent or Guardian
*
First Name
Last Name
Understanding and Acknowledgment
*
I understand that:
These services are confidential, and my child’s healthcare provider will not disclose information to me without my child’s consent unless required by law. I have the right to ask questions about the services and to refuse any service I do not want for my child. By selecting yes below, I acknowledge that I have read and understand the above information and consent to my child receiving the selected health services.
Release of Information
*
I, as the parent or guardian authorize the school to share demographic information with the Health Yeah! program..
Voluntary Authorization
*
I understand that this authorization is voluntary and not a prerequisite for the student to receive healthcare services. Choosing not to sign will not impact the student’s eligibility for treatment, enrollment in the Health Yeah! program, or access to benefits.
Thank you for completing the Health Yeah! consent form. We will enter your information into our database so your student can begin receiving care.
In the meantime, please download the Health Yeah! app
