School Physical and Tdap Immunization Event Registration

Pasco County Schools, in collaboration with Premier Community Healthcare Group, inc. (hereinafter, Premier), will be hosting a School Sports Physical, School Entry Physical, and Required School Immunizations Event, at the Hudson Community Health & Resource Center. Appointments are limited be sure to fill the form out as soon as possible. Premier will have a medical provider on site to provide the physicals and immunizations. In order for Pasco County Schools to assist with and initiate this opportunity, we need your parental consent in accordance with the Parents' Bill of Rights (Ch. 1014, F.S.) and FERPA (20 U.S.C. 1232g). If consent is provided, Premier will be reaching out to you to schedule your student's physical and obtain the necessary insurance, income, and medical information needed, along with their own consent to provide services. Premier will provide school physicals and immunizations to children regardless of insurance status. Pasco County Schools will not be able to view any of the information that you provide to Premier. The consent below allows Pasco County Schools to initiate this referral opportunity and to share your parental contact information with Premier.

Student Name Student Name First Last
Student's Date of Birth Student's Date of Birth / MM / DD YYYY
Parent's / Guardian's Name Parent's / Guardian's Name First Last
Student's Address Student's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent's / Guardian's email address
Parent's / Guardian's Cell Phone Parent's / Guardian's Cell Phone - ### - ### ####
Parent's / Guardian's Land Line Number Parent's / Guardian's Land Line Number - ### - ### ####
What services are you requesting?

What services are you requesting? Sports Physical School Entry Physical Required School Immunizations
By my electronic signature below, I am authenticating that I am the child's parent / guardian, with the right to execute this authorization in accordance with the Parents' Bill of Rights, and that I understand, agree, and authorize Pasco County Schools to initiate a referral for the above-referenced services and to share my contact information with Premier for the purposes of arranging a physical visit. I understand that this consent and authorization will only be in effect for the enrollment process of the current school year, or until I revoke such consent in writing to the school nurse of my child's school, whichever comes first.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.