Registration Forms

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 * are requied

Student Details
Contact Details

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.


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