Consent to Participate

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Senate Bill 12 requires permission from parents for their child to participate in student clubs, activities, counseling, health services and/or prayer authorized or sponsored by St. Mary's Academy Charter School. You may provide consent for your child to participate in any and all through this form or deny consent and require permission before your child can participate in any of the below activities. This permission form is effective immediately and remains in effect for the 2025 - 2026 school year. The law requires school districts to obtain this consent from the parent / guardian annually. Permission can be revoked / granted at any time. A change in permission must be provided by submitting the form by the parent / guardian, and is effective immediately upon receipt by the school administration. Please complete a separate form for each child.

Email *

Record my email address with my response

Student Name *

Parent or Guardian Name(s) *

Parent / Guardian Contact Number *

Grade Level *

Homeroom Teacher *

Parental Consent for Clubs or Extracurricular Activities:

ACE

I hereby grant permission for my child to participate in any student club or extracurricular activity authorized or sponsored by SMACS.

My child cannot participate in any student club without my expressed written permission.

Parental Consent for Individual, short term, Counseling is provided by the school counselor and covers topics such as:

Early mental health prevention and intervention; building skills relate to managing emotions; establishing and maintaining positive relationships; responsible decision-making; grief-informed and trauma-informed intervention; positive behavior interventions and supports; positive youth development; and safe, supportive, and positive school climate; general mental health related services. NOTICE if you opt out of individual counseling services, your child will not be allowed to talk to anyone should they become upset about anything at school.

I hereby grant permission for my child to participate in individual general mental health related services.

My child may not see the counselor for individual counseling.

Parental Consent for large group Counseling. These sessions are provided by the school counselor and take place in the classroom about once a month and cover character ed topics including, but not limited to, Bullying, Kindness, Self-Esteem, Trustworthiness, Respect, Responsibility, Fairness, and Citizenship. *

I hereby grant permission for my child to participate in large group Counseling.

My child may not participate in large group Counseling.

Parental Consent for Health Related Services. School health-related services are most often provided by the school nurse. However, additional school staff may also provide first aid and care for ill or injured students. These school staff members include, but are not limited to, teachers, coaches, front office staff, administrators, counselors, and other staff who supervise children. Health related services in the school setting may include, but are not limited to:

Acute/immediate care of illness or injury

Assess heart, lungs, and body systems

Vision and Hearing Screening

Examination of pupil responsiveness

Seizure and traumatic injury response

Heat illness response and prevention

Injury of student

Evaluate vital signs, temperature, blood pressure, pulse, respiratory rate, and oxygen saturation

Physician collaboration

Lice screenings

Spinal screening

Acanthosis screening

Diabetes education

Diabetic response

Immunization review

Blood pressure and pulse monitoring

Procedures prescribed by a physician

Health education and consultation

Concussion / cardiac emergency protocols

Medication administration

Provide bandages if needed

Provide sanitary products if needed

This consent DOES NOT AUTHORIZE: Invasive screenings or procedures, collection or sharing of biometric identifiers, and preventative health care such as laboratory draws, swabs, or vaccine administration.

PLEASE BE ADVISED that if you choose to opt out of these services, and your child becomes ill or sustains a non-life threatening injury during the school day, the school WILL NOT be permitted to assess or provide care, except for a life-threatening emergency. In such cases, you will be contacted immediately and will be required to pick up your child from school without delay to attend to your child's health-related needs.

I hereby grant permission for my child to receive health-related services.

My child is not allowed to participate in any health-related services.

Add any comments here:

If you have another child, after you click submit, you will be asked if you want to submit another form. Click yes, and then complete for the next child. Please make sure to submit a form for EACH child.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of St. Mary's Academy Charter School.

Does this form look suspicious? Report

Forms