Oakland High School - SHOP 55 Wellness Center Forms (2021-2022)
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The form will include the following sections for you to review, acknowledge, or consent to services provided through the SHOP 55 Wellness Center & Expanded Learning Program (EBAYC and AHS).

A link to view the above documents are embedded in the form.

If you have any questions, please contact SHOP 55 Wellness Center Director at rany@ebayc.org
Student's FIRST Name *
Student's LAST Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Student ID#
You may ask student OR leave blank if you do not know.
Student Cell Phone Number, if available
By providing a student cell phone number, you are giving Oakland High staff and partners permission to contact the student. Primary reasons for contacting student is to check in on their well-being, offer support, and coordinate services.
Parent/Guardian Primary Phone Number(s)
If you have not received any phone call or text message from Oakland High School, please provide an updated phone number here.
Parent/Guardian Email
If you have not received an email from Oakland High School, please provide an updated email here.
Parent/ Guardian Name that is completing this form *
IMAGE ONLY: SHOP 55 Wellness Center & After School Program Consent (Page 1 of 3)
IMAGE ONLY - SHOP 55 Wellness Center & After School Program Consent (Page 2 of 3)
Please check off which EBAYC services you'd like your student to have access to. If you want your student to have access to all services, please check off the first box. By allowing access now, you or student can choose to accept or decline at any time. *
Most services can be offered virtually and in-person EXCEPT for one, which is noted below.
Required
EBAYC has informed me that my child may be interviewed and photographed, and/or videotaped for the purpose of publicizing the work of EBAYC. I hereby give the EBAYC the right to use my child’s name, picture, portrait, photograph, video and audio recording for advertising or any other lawful purposes, and I waive any right to inspect or approve the finished version(s). *
I do hereby for my child, myself, my heirs, executors and administrators, fully release and discharge EBAYC, its officers, agents, employees, and volunteers from all claims, demands and causes of action of any kind whatsoever which may be sustained as a result of my child’s participation in the activities, services, and programs of EBAYC. *
By checking this box, indicates you have read and agree to the terms of the EBAYC Parent/Guardian Consent. This is standard legal language for all our programs and services.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. By entering my name below, I am agreeing that I'm authorized to complete the EBAYC SHOP 55 Wellness Center & After School Program form on behalf of the child listed above and I certify all information entered on this form is true and correct to the best of my knowledge. *
Please print your name to acknowledge your preferences above.
IMAGE ONLY - Asian Health Services (AHS) is the lead medical agency at SHOP 55 Wellness Center. Below is the list of services they can offer, such as immunizations, health insurance eligibility check, and individual therapy.
IMAGE ONLY - Note: All services are free of charge at SHOP 55 Wellness Center. This is only standard protocol for AHS.
IMAGE ONLY - To view AHS Privacy Practices: https://tinyurl.com/SHOP55ahsConsent
Asian Health Services *
To view original documents: https://tinyurl.com/SHOP55ahsConsent
Name of Health Insurance Company *
This will only be used to conduct sports physicals. If not, please put none. If you decline to answer, you may put decline.
Health Insurance Policy Number *
This will only be used to conduct sports physicals. If not, please put none. If you decline to answer, you may put decline.
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