REQUIRED FORM 

RISE CHARTER SCHOOL 

Blanket Consent Form for Health Care Services for Minors  
 

Providing blanket consent is optional and may, instead, be given on a case-by-case basis. Blanket consent may be withdrawn by a parent at any time. 

[Note: This title must be in bold, 30-point font and the sub-header must be in bold, 24-point font.]  

 
[NOTE: This form is to be provided to students’ parents/guardians at the beginning of each school year.]  

Dear parent or guardian, 

The purpose of this form and the attached copy of the Charter School’s policy on Student Health/Physical Screenings/Examinations is to provide notice of all health services offered or made available through the School by the Charter School or by any private organizations and to provide notice of the School’s policy on physical examinations and screening of students and to obtain parent/guardian consent for these services.  

The Charter School will provide, under reasonable circumstances, nonemergency first aid services to a child appearing or representing to be sick or injured, such as dressing minor wounds, applying topical agents, providing fluids or ice, and performing checks to identify minor illnesses.  
 
The blanket consent requested in this form applies only to the health services or examinations for which the parent/guardian has provided permission below. A parent or guardian is not required to provide blanket consent. If blanket consent is not provided, the School will seek consent on a case-by-case basis when consent is required. This blanket consent does not limit or replace the School’s authority or obligation to respond to a medical emergency. Consistent with Idaho law and School policy, the School may provide health care services without prior parent/guardian consent when School staff reasonably determine that a medical emergency exists and: 

• The health care service is necessary to prevent the minor child’s death or address serious bodily harm; or  

• Despite a reasonably diligent effort, School staff are unable to contact the parent or guardian, and the health care service is furnished to prevent loss of life or serious physical illness or injury to the minor child.  

Emergency care provided under these circumstances is not conditioned on the parent or guardian signing this blanket consent form. 

The School will provide the following additional health services or examinations which can only be provided with parental permission or in the event of an emergency as described above:  

 
Parent Emergency Contact Information 

Parent 1: Emergency Contact Name: _______________________________________________ 

Emergency Contact Phone Number: __________________________________________ 

Emergency Contact Email Address: __________________________________________ 

Parent 2: Emergency Contact Name: _______________________________________________ 

Emergency Contact Phone Number: __________________________________________ 

Emergency Contact Email Address: __________________________________________ 

Please select one of the following options:  

_____ I hereby designate the following emergency contact for my child and grant them authority to consent to health care services provided by the school in the absence of the School’s ability to reach me. 

Emergency Contact Name: _________________________________________________ 

Emergency Contact Phone Number: __________________________________________ 

Emergency Contact Email Address: __________________________________________ 

_____ I do NOT wish to designate an emergency contact to consent to health care services provided by the school in the absence of the School’s ability to reach me.  

 Acknowledgment and Authorization 

Please select one of the following: 

_____ Blanket Consent: I have read and understand the School’s policy on student health services. I voluntarily provide blanket consent for the services indicated in the table above. I understand that I am not required to provide blanket consent and that I have a right to withdraw this consent at any time by notifying the School in writing. 

_____ Case-by-Case Consent: I decline to provide blanket consent at this time. I will provide consent on a case-by-case basis for each health service requested by the School. 

           _____________________________________________________ 
          Student Name 
 
 
          _____________________________________________________              _______________________ 
         Parent Signature Date 

          _____________________________________________________ 
          Parent Name 
 

Policy History: 

Adopted on: September 21, 2026 

Revised on: 

Reviewed on: