Inclusion Support Services | Informed Consent | Vision and/or DHH

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SD46 Informed Consent for students supported by the District Vision Teacher and/or the District Teacher of the Deaf and Hard of Hearing

- Step 1 of 4

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 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 give my permission to School District 46 specialist(s), to consult and/or to assess my child and to provide assessment findings, recommendations, services, resources and training to school/district personnel (e.g. Principal, Teacher, EA, District Support Staff). (Check all that apply)

Vision Teacher
Teacher of the Deaf and Hard of Hearing

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.

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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SD46 Informed Consent for students supported by the District Vision Teacher and/or the District Teacher of the Deaf and Hard of Hearing

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 1: Student/Parent/Guardian Information

Section 2: Consent for Assessment/Consultation

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

Section 4: Parent/Guardian Consent

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