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Logo for KanLovKids Low Vision Collaboration Clinics, the state of Kansas with a magnifier over a heart; the words KanLovKids Clinic Programs; and the logo for the Kansas State School for the Blind, a flying blue eagle in the middle of a red and yellow sunflower.

Participation and Consent Form

A KanLovKids Low Vision Collaboration Clinic (LVCC) or Low Vision Collaboration Clinic + (LVCC +) is only intended to determine which low vision devices and strategies will assist children in completing educational goals. Because the clinic does not provide a complete medical examination of the eyes, the doctor recommends that all participating children receive a separate full medical eye examination at least every three years. The clinic doctor is able to provide referrals for full medical eye examinations upon request.

The clinic participant will be scheduled to receive services only after all necessary records are received by KSSB. This consent form is valid for one calendar year from the date it is signed. If the required records are not received within one calendar year, a new consent form will be required.

All services of the Kansas State School for the Blind (KSSB) are a part of the public education system of the state of Kansas. Records obtained or produced by KSSB’s employees and contractors in connection with these activities become a part of the child’s educational records and are protected under state law and the federal Family Educational Rights and Privacy Act (FERPA). Other educational entities are able to disclose relevant educational records to KSSB without additional consent. For additional details on family and student rights related to educational records at KSSB, please see the Student/Parent Handbook on the school’s website.

Authorization for the release and/or discussion of protected health information to be sent to
Molly Reardon, Kansas State School for the Blind, KanLovKids Coordinator

Student's Name
Student's Name
Date of Birth
Date of Birth


Parent/Guardian Name

hereby authorize

Name of Eye Clinic/Doctor
Phone Number
Fax Number
to release and/or discuss the following information:
Information to be released
Specified Information

To be sent to: Molly Reardon, Kansas State School for the Blind, KanLovKids Coordinator
1100 State Avenue, Kansas City, KS 66102, email: or fax: 913-621-2310

I have carefully read and understand the above information, and do herein consent to its disclosure. I am aware that information regarding my medical condition will be released to those persons or agencies named above. I understand that this consent is subject to revocation, in writing, at any time, unless action based on it has already begun. This authorization expires one year from today's date.

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