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Parent/Legal Guardian #1


Parent/Legal Guardian #1



SingleMarriedCivil UnionLiving TogetherSeparatedDivorcedWidowed

Very wellWellNot wellNot at all

NoYes, it is:SpanishFrenchASLOther

Employed Full-timeEmployed Part-timeUnemployedRetiredReceivingDisability

We own homeRentPublic HousingSection 8Live with Family/FriendsHomelessShelter

Live with Parent/GuardianIn Foster CareGroup HomeLive with FriendsLive with Relatives

SNAP (Supplemental Nutrition Assistance Program)WIC (Women, Infants, and Children Nutrition Program)Health Insurance Benefits (HUSKY, Medicaid, etc.)TANF (Temporary Assistance to Needy Families)EITC (Earned Income Tax Credit)


Certification and Consent:

I hereby certify that the information on this form is complete and correct to the best of my knowledge. I consent to have this information entered and saved into the LifeBridge Community Services confidential client database. I understand that client records are confidential and are not released or shared with anyone outside of LifeBridge Community Services without the parent/guardian’s written consent except as required by law.

I have read the Urban Scholars Program responsibilities and both my Scholar and I agree to meet those expectations.

I give my permission for my child to be photographed, recorded, and/or videotaped by LifeBridge Community Services during agency-sponsored activities. I also understand that these photos, audio, and/or videotapes may be used in future publications, as marketing material or as training material.

I understand that LifeBridge Community Services is operating the Urban Scholars Program with great care, but that COVID-19 is a transmittable disease and my child is only in LifeBridge’s care during the daytime program. I cannot hold LifeBridge Community Services liable if my child contracts COVID-19 or any other transmissible illness.

I give my permission for (Scholar’s name) to attend the Urban Scholars Summer Program at LifeBridge Community Services and to participate in all activities, subject to the authority of the Urban Scholars Program Director.

URBAN SCHOLARS PROGRAM HEALTH HISTORY FORM

Medicaid/HuskyMedicareNo InsuranceOther

Health History Information:

PERMISSION TO TREAT

Connecticut law states that except in the case of an emergency which threatens life or limb, parent or guardian must sign consent to treat for a patient under the age of 18. Please complete this section to allow your child to receive treatment for an accident, injury or illness at a medical facility.

  • Scholar will be transported to Bridgeport Hospital
  • Program staff will always notify parent/guardian of need for medical care.
  • Scholar Health History and Registration Forms will be shared with the Medical Facility staff.

I request and authorize, Southwest Community Health Care Center or Bridgeport Hospital, or nearest medical center, and its personnel to deliver medical care to my child listed here: . I also authorize LifeBridge Community Services to share Scholar Health History with the Medical Provider. This authorization will expire one year from the date of signature unless otherwise stated.

This health history is correct so far as I know and the person herein described has permission to engage in all prescribed program activities except as noted. EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel selected by the Urban Scholar Director to order x-rays, routine tests and treatment for me(staff) or my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Urban Scholar Director to hospitalize, secure treatment for and to order injection and/ or anesthesia and/or surgery for me(staff)/or my child as named above. This form may be photo-copied for use off property. I also give permission for the Urban Scholar Program to provide routine medical care for my child.

PLAN OF CARE


Strict AvoidanceMedication as required. Please attach medical provider’s order/ care plan.Other




HearingVision