Low Vision Collaboration Clinic+ Consultation Program KanLovKids Clinic Participation and Consent Form A KanLovKids Low Vision Consultation is a platform that can be utilized when visits to clinics are not an option. It provides parents and other team members the opportunity to ask questions and receive recommendations based on video observations and team discussions.It is recommended that your child attend a Low Vision Collaboration Clinic + (LVCC +) for a full evaluation when possible. These evaluations are 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.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.By agreeing to participation in the KanLovKids program, you also give KSSB consent to request relevant health records from medical professionals who have examined and cared for the clinic participant in the past. This information will be disclosed to the school in accordance with the Health Insurance Portability and Accountability Act (HIPAA), which does not require a separate signed consent for disclosing records related to these treatment activities.The 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. By signing below, you are indicating that you have read and understand the information provided above, and that you agree to participate in the KanLovKids program.By signing below, you are indicating that you have read and understand the information provided above, and that you agree to participate in the KanLovKids clinic program.Full Legal Name of Clinic Participant First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature of Clinic Participant (if over 18 years old)DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature of Parent or Guardian (if Clinic Participant is under 18 years old)DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
