Get Parent/guardian Permission Form

Filling out the Parent/Guardian Permission Form is a vital step in ensuring your child receives proper eye care services. This guide will provide you with clear, step-by-step instructions to complete the form online with ease.

Follow the steps to complete the online form.

1. Press the ‘Get Form’ button to access the permission form and open it in your browser.
2. Begin by entering your child's name and home phone number. Make sure to provide accurate details as they are essential for identification.
3. Fill in your child's CCSD ID number and date of birth. These fields are important for the clinic’s records.
4. Indicate your child's gender by selecting either 'Male' or 'Female'.
5. Complete the home address section, including city, state, and zip code.
6. Provide your child's school information to help with any necessary correspondence.
7. Specify your child's ethnicity by circling only one option from the provided list.
8. Indicate your child's race by circling one or more options as applicable.
9. Enter the name and contact numbers of the parent or guardian completing the form.
10. Provide a valid email address for any future communications.
11. If applicable, circle 'Yes' or 'No' to indicate whether your child is enrolled in Medicaid and provide the Medicaid number.
12. List any allergies your child may have, ensuring to include all relevant information.
13. Fill in the name and contact number of your child's physician.
14. Provide emergency contact information in case of an urgent situation.
15. Select what type of exam is being requested: either for an exam or eyeglasses, and provide the date of the last eye exam.
16. Indicate whether your child currently wears glasses. If yes, remind to bring the glasses to the appointment.
17. Describe the eye problem you are seeking help for.
18. Read and acknowledge the permission section, then select 'Yes' or 'No' regarding the photograph or video usage.
19. Sign and date the form, and print your name clearly for record-keeping.
20. Once all fields are complete, save the document, download it for your records, print a copy as needed, or share it with the relevant office.

Complete the Parent/Guardian Permission Form online today to ensure your child receives the necessary care.