RRH School-Based Health Center Enrollment

School-Based Health Center Enrollment
Our School-Based Health Center provides medical and behavioral health services within a safe, comfortable school environment, so that high-quality care is within easy access to students regardless of current situation. Services in this program are provided at no direct cost to the student or family. Costs are covered by your health insurance, the New York State Health Department, federal grants and Rochester Regional Health grants.

The School-Based Health Center is staffed by caring and dedicated Licensed Social Workers/ Mental Health Therapists, Psychiatrists, Nurse Practitioners, Pediatricians and Medical Assistants, Outreach Workers and Office Assistants. These professionals are committed to providing care and support for students in need, and to working closely with the family’s regular doctor in the community to ensure that each student receives consistent care.

Learn more about our School-Based Health Centers
Student Information
What school does the student attend?*

John James Audubon School #33Dr. Freddie Thomas Middle SchoolDr. Martin Luther King Jr. School #9Edison Career and Technology High SchoolThurgood Marshall Middle School
Student Name*

First NameLast Name
Student Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student Date of Birth*

MonthDayYear
Date
Student Contact Number*
Please enter a valid phone number.
Is it okay to text this number?*

YesNoNA
Student's preferred email (enter NA if none)*
example@example.com
Is it ok for the Health Center to email student?*

YesNo
Student's preferred form of communication*

EmailPhoneText
Student Current Grade*
Student Gender*

FemaleMaleNon-binaryPrefer not to say
Student Ethnicity*

American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” can be used in addition to “Black or African American.Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to "Hispanic or Latino."Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.Caucasian. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.Prefer not to sayOther
Is the student 18+ or emancipated?*

YesNo

Parent/Guardian Information
Parent/Guardian's Name*

First NameLast Name
Parent/Guardian's Relationship to Student*
Parent/Guardian's Address (if different than the student)

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian's preferred contact phone number*
Please enter a valid phone number.
Parent/Guardian's email (enter NA if none)*
example@example.com
Parent/Guardian/s preferred method of contact*

EmailPhoneText
Is it ok for the Health Center to email parent/guardian?*

YesNoNA

Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.

Student Medical History
Student’s Primary Care Provider*
Write NA if child has no provider
Student’s Mental Health Provider*
Write NA if child has no provider
Does the student have allergies?

NoYes
Student's Allergies
Does the student currently have any medications?

NoYes
Student's Medications
Does the students have any health conditions/problems?

NoYes
Student's Health Conditions/Problems
Are there any other concerns regarding student's health?

NoYes
Please share concern's regarding student's health

School-Based Health Center Enrollment

Student Information

Parent/Guardian Information

Student Medical History

Student Health Insurance Information

CONSENT TO TREATMENT