KanLovKids Clinic Programs
Permission and Record Release Form
I have read this consent letter and understand the purpose and procedures of this project. I freely and voluntarily choose to participate and have my son or daughter participate. I agree to allow the school/doctor’s office to release information regarding my child’s vision, i.e., most current ophthalmology report, functional vision assessment, orientation and mobility evaluations, and IEP goals and objectives.
I authorize and give permission to the KanLovKids clinics/Kansas State School for the Blind to obtain or provide information to my child’s school district and IEP team members for programming and collaboration. Low vision evaluation information will be kept confidentially with the KLK coordinator and KSSB field service staff.
Child's Name (First and Last)
MM slash DD slash YYYY
MM slash DD slash YYYY
Printed Name of Parent/Guardian
Final report will be emailed to the email address provided from KanLovKids Notifications.
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