Student Triannual Consent Form

Student Triannual Consent Form

Student Information

Student Name:

Date of Birth:     Student ID:

Parent / Guardian Information (if student under 18)

Relationship:     Preferred Phone:

Emergency & Medical Information

Emergency Contact Name:     Relationship:

Emergency Phone:     Alternate Phone:

Triannual Consents (check each box to authorize)

I consent to the student's participation in routine school activities, classroom instruction, and supervised on-campus programs during this triannual period. I authorize staff to provide routine supervision and basic first aid as necessary.

I consent to the student's participation in local field trips and walking excursions within the community under school supervision.

I consent to the student's participation in non-local field trips and off-campus activities. I understand that additional information and event-specific permission may be provided prior to travel and that overnight or high-risk activities may require separate written authorization.

In the event of illness or injury, I authorize the school to obtain necessary emergency medical treatment, including transportation to a medical facility. I authorize school personnel to disclose relevant health information to emergency responders and treating providers. I acknowledge the school's efforts to contact me and understand that this authorization is given in circumstances where immediate medical care is required.

I authorize school personnel to administer prescribed medication(s) and school-authorized over-the-counter medication(s) to the student in accordance with submitted written instructions from the prescribing provider and the parent/guardian. I will provide current written medication orders and replacement medication as required.

I consent to the student receiving school-provided counseling or telehealth behavioral health services when deemed appropriate by school staff. I understand limits to confidentiality apply where there is concern for safety or as otherwise required by law.

I grant permission for the student's image or recorded voice to be used by the school in internal and school-related publications, educational materials, or non-commercial media. I understand the school will not disclose contact information in such materials without separate consent.

I authorize the release of directory and educational information to third parties for school-related purposes as permitted by policy. I understand that more sensitive records will require additional authorization and that this consent may be revoked in writing.

Acknowledgments, Limitations, and Period of Consent

By signing below, I certify that the medical and emergency information provided is accurate to the best of my knowledge. I understand that the consents checked above authorize the school to act consistent with each checked item for the triannual period specified below. This authorization remains in effect for the period beginning: Start Date: and ending: End Date: unless I revoke consent in writing sooner.

I understand that the school will take reasonable precautions to safeguard the student's health and safety, but I release the school and its employees from liability for actions taken in good faith under this consent, except for gross negligence or willful misconduct. I further understand that actions taken prior to receipt of any written revocation shall not be affected by such revocation.

If the student is 18 years of age or older, the student is permitted to sign for themselves. If signing on behalf of a minor, the signer affirms they are the parent or legal guardian and have authority to provide these consents.

Is the student 18 years of age or older and signing on their own behalf?

Additional Notes (Optional)

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