Inclusion Support Services | Informed Consent and Consent to Obtain/Release Information | Therapy Services

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Inclusion Support Services | Informed Consent and Consent to Obtain/Release Information | Therapy Services

This informed consent is intended to help ensure that you have been adequately informed about the services offered to you and what they entail before consenting to them.

- Step 1 of 4

As a parent/guardian, completing the Informed Consent form for School District 46 is a vital step in proceeding with district supports for your child. Please carefully read through every section of the form. Ensure all the information provided is accurate, as it directly affects the services your child will receive. Should there be any segment of the form that remains unclear or any service that you may have questions about, please don’t hesitate to reach out directly to your child’s school. They are well-prepared to provide additional information and address any of your concerns.

Section 1: Student/Parent/Guardian Information

Student's Name *

First

Last

Student's Date of Birth *

School *

Cedar Grove Elementary School
Chatelech Secondary School
Davis Bay Elementary School
Elphinstone Secondary School
Gibsons Elementary School
Halfmoon Bay Elementary School
Kinnikinnick Elementary School
Langdale Elementary School
Madeira Park Elementary School
Pender Harbour Secondary School
Roberts Creek Elementary School
SPIDER
Sunshine Coast Alternative School
West Sechelt Elementary School

Grade *

Teacher/Homeroom *

Family Doctor *

Parent/Guardian *

First

Last

Parent/Guardian

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Section 2: Consent for Assessment/Consultation

I, the undersigned, hereby extend my explicit and informed consent to enable specialist(s) affiliated with School District 46 to conduct consultations and/or assessments of my child. I also authorize the said specialist(s) to provide comprehensive details of these assessment outcomes, informed recommendations, essential services, required resources, and pertinent training to the relevant school/district personnel, including but not limited to, the Principal, Teacher, Educational Assistant (EA), and District Support Staff. This consent applies to all applicable areas as indicated by the checked boxes. It is important to understand that this informed consent will remain effective throughout my child's enrolment period within School District 46. This informed consent is intended to be continuous, remaining valid and operative for the entire duration of my child's association with School District 46, unless withdrawn or modified by my express written instruction.

Occupational Therapy
Physical Therapy
Speech-Language Pathologist

I also understand that a copy of the report(s) prepared by the specialist(s) identified above, will be sent to the school and placed in the student’s file. The school copy of the report will be provided to school/district personnel authorized to provide educational services to this student. I understand that the reports, services and educational plans arising from the assessment/consultation provided by the specialist(s) can be discussed with me and that a copy of subsequent reports will be made available. At any time, I may revoke consent for the above consultation, assessment, support and/or services either verbally or in written form.

Information sharing and collaboration with other professionals/agencies helps to ensure appropriate and coordinated services are available to students. This form allows parents/guardians an opportunity to determine which agencies the school district may consult with in relation to their child.

Section 3: Consent for Obtaining/Releasing Information to/from Outside Agencies

Please select an option:

No, I do not give consent to obtain or release information
Yes, as the parent or guardian of the student named above, I give consent for the obtaining and releasing of information to the services checked below:

With regards to my child's educational program, I hereby give permission for School District 46 (Sunshine Coast) staff to obtain information from and release information to the following persons/agencies

Name of Contact Person at Agency

Phone Number of Contact Person at Agency

And, with regards to my child's educational program, I hereby give permission for School District 46 (Sunshine Coast) staff to obtain information from and release information to the following persons/agencies

Name of Contact Person at Agency

Phone Number of Contact Person at Agency

Other (Please list any additional Agencies, Contact Name and Phone Number)

Section 4: Parent/Guardian Consent

I have had an opportunity to ask questions and have been provided satisfactory answers to any questions or concerns regarding services and my informed consent. I have voluntarily completed this form, and I feel comfortable giving my consent for services for my child. *

Yes
No, I need more information

I am the parent or guardian of this student and I am legally able to give consent on behalf of this student. *

Agree
Disagree

Parent/Guardian Signature *

Clear Signature

Dated *

Contact

Sunshine Coast School District 46 – 494 South Fletcher Road,
PO Box 220, Gibsons, BC, V0N 1V0 Canada

(604) 886-8811
questions@sd46.bc.ca

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Inclusion Support Services | Informed Consent and Consent to Obtain/Release Information | Therapy Services

Section 1: Student/Parent/Guardian Information

Section 2: Consent for Assessment/Consultation

Information sharing and collaboration with other professionals/agencies helps to ensure appropriate and coordinated services are available to students. This form allows parents/guardians an opportunity to determine which agencies the school district may consult with in relation to their child.

Section 3: Consent for Obtaining/Releasing Information to/from Outside Agencies

Section 4: Parent/Guardian Consent

Contact

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