Use this form to enroll your child in Hometown’s School-Based Health Center services. It has two parts: the parental consent form and the student registration. Need a paper copy mailed to you? Call (518) 370-1441.
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1044 State Street, Schenectady, NY 12307 · (518) 370-1441 · hometownhealthcenters.org
School-Based Health Center Services — Parental Consent Form
Hometown Health Centers
I (Print Name) certify that I am the parent or legal guardian of:
Print Student Name
Student Date of Birth
Hometown Health Centers
Hometown Health Centers (www.HometownHealthCenters.org) is a nonprofit community health center given permission by the Federal government and State of New York to provide health services.
Consent and Authorization for Providing Care
I consent and authorize Hometown Health Centers through its school based program to provide medical and behavioral health services if my child asks for such services. These services may include, but not be limited to: tests, referrals, screenings, examinations, evaluations, assessments, medical and behavioral health care, and education and counseling. My child will be encouraged to involve me in counseling and medical decisions.
I understand when State required Immunizations are due, an attempt will be made to discuss mandatory immunizations prior to the visit, if I am not available, Hometown Health Centers through its school based program will give the required immunization.
In addition, I consent and authorize Hometown Health Centers through its school based program to provide the following optional immunization for my child (please initial each vaccine you are authorizing):
Human Papillomavirus (HPV) Flu Meningitis B Hepatitis A Covid
Consent and Authorization for Release and Discussion of Information
I authorize my child’s school or primary care provider to release copies of physical exams, medication histories, and immunization record to Hometown. This release includes permitting the school and primary care provider to discuss my child’s healthcare directly with Hometown.
I understand that by law, parental consent is not required for prenatal care, services related to sexual behavior, mental health care and pregnancy prevention, and the provision of services where the health of the student appears to be endangered. Parental consent is not required for students over 18 years or those who are parents or are emancipated.
Confidentiality and Legal Requirements
I understand that confidentiality between my child and Hometown’s health provider may be required under New York State Law, though may be disclosed to third party payers for billing purposes. I understand New York State law requires certain health information be shared with the school nurse. Information not required to be shared will be done solely at the discretion of the Hometown healthcare professional caring for my child.
I understand Hometown may consult and communicate with other healthcare professionals regarding care by providing or requesting patient information about my child.
Care without Contact
I understand my child will be provided medical or behavioral health services, should my child do so of their own free will. If my child requests I be informed, a good faith effort will be made to reach me first, but in the event, this does not occur, it will be in the provider’s discretion and that of my child to go ahead with treatment. I further understand at the child’s request and in accordance with State and Federal privacy laws certain information may not be disclosed to me, even though a parent or guardian.
Revoking Consent and Authorization
I further understand my consent and authorization for all health care services, including primary care and behavioral health, and the release and discussion of healthcare information shall remain in effect, regardless of school or educational grade, unless I provide written notice to Hometown Health Centers revoking it. Hence, this authorization may last multiple years, unless revoked.
Signature
Date
Parent / Guardian (Print Name)
Home phone
Day time phone
Cell phone
1044 State Street, Schenectady, NY 12307 · (518) 370-1441 · hometownhealthcenters.org
Hometown Health Centers School-Based Health Center Registration
Student Information
Student’s Last Name
Student’s First Name
Student’s Middle Initial
Date of Birth (Month / Day / Year)
Student’s Social Security Number
Student’s School
Grade
Sex:
Ethnicity:
Race:
Preferred Language
Student’s Address
City
State
Zip Code
Insurance Information
Does the child have health insurance?
Name of Health Insurance Company
Insurance ID #
Group #
Policy Holder
Relationship to patient
Policy Holder’s Date of Birth
Policy Holder’s Sex
If your child does not have health insurance, would you like to be contacted by a Hometown Health Centers Enrollment Specialist who can assist you with obtaining free or low-cost health insurance?
Parent/Guardian Information
Mother
Last Name
First Name
Father
Last Name
First Name
Legal Guardian, If Applicable
Last Name
First Name
Relationship of Legal Guardian to Student:
Contact Information for Parent or Guardian
Home Tel
Work Tel
Cell
Email address
I give my permission for HHC to contact me via (select all that apply):
Who is the student’s regular doctor?
Name
Telephone
Address
*Pharmacy – all prescriptions will be transmitted to College Hometown Pharmacy at Hometown Health Centers, 1044 State Street, Schenectady, unless otherwise identified below.
Pharmacy Name
Pharmacy Phone #
Hometown Health Administrative Use Only
HHC Staff Name
HHC Staff Signature
Date Completed