Pathways Program Consent for Services
Please complete this form and submit it. This will get copied to our administrators of the program and you will get a chance to print the form to sign and bring an original for our records.
Items marked *
Consent
I consent to have my son or daughter receive services provided by PATHWAYS, Carteret’s School-based Youth Services Program, including those provided by the Nurse Practitioner, with the exception of the specific services I have noted below (if any).
I understand that clinical documents are confidential and may only be released with consent or at the professional discretion of the SBYSP employee. I further understand I will be contacted if my child needs medical attention beyond what can be provided on site by the Nurse Practitioner.
After you have completed this form you will be given a chance to download it as a PDF. This will let you print it so you can sign it and return it to us.
submit
Thank you for your submission.
Here you can download your consent form as a PDF to print and sign.
NOTE: this form must be signed by a parent or legal guardian and submitted to the Pathways office in Carteret High School. Your child may bring this form directly to the Pathways office. If you are mailing this form, please put to the attention of Pathways Program, Carteret High School, 199 Washington Ave., Carteret, NJ 07008.
Wellspring Center for Prevention
Promoting Healthy Living Through Education, Training & Advocacy
