COVID-19 Medical Eligibility Form for Virtual Instruction
This from is to be completed by the parent/ guardian.  

Link to Information regarding Medical Eligibility -  

Additional Information Required
Please email, fax or drop off the Medical Eligibility Form for Virtual Instruction completed by your child's health care provider.

1.  Email Superintendent Chris Pettograsso - cpettograsso@lcsd.k12.ny.us 
2.  FAX Attention Chris Pettograsso: 607-533-3602
3.  District Office, 284 Ridge Road, Lansing, NY 14882

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Email *
Student First Name *
Student Last Name *
Student Address *
Student Grade *
Required
PARENT/ GUARDIAN CONSENT:  I hereby authorize my child's health care provider listed in the next question and Lansing Central School District (LCSD) to discuss, release, or exchange information, contained in or related to this form, or release information from my child's education and medical records concerning my request for virtual enrollment for the above-referenced student due to COVID-19. I understand that the information that is discussed, released, or exchanged may be written and/or verbal, and will only be discussed, released, or exchanged for the purpose of determining whether virtual enrollment is appropriate for the above-referenced student. Further, I understand that COVID-19 virtual enrollment requests are subject to approval by LCSD based on the following criteria: • Documentation of a health/medical need due to COVID-19 from a licensed medical provider [Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Physician Assistant (PA) or Advanced Practice Registered Nurse (APRN)]; AND, • Documentation from a licensed medical provider indicating that the student REQUIRE virtual instruction because of a health/medical need due to COVID-19.     *
Please list your child's heath care provider (s) that you provide the above consent to. *
A copy of your responses will be emailed to the address you provided.
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