Emergency Information

Student 1 Last Name *

Student 1 First Name *

Birthdate *

Grade *

Student 2 Last Name

Student 2 First Name

Birthdate

Grade

Student 3 Last Name

Student 3 First Name

Birthdate

Grade

Student 4 Last Name

Student 4 First Name

Birthdate

Grade

Legal Street Address *

City *

State *

Zip *

Home Phone Number *

Mother's Name

Cell #

Work #

Name of Employer

Father's Name

Cell #

Work #

Name of Employer

Father's address if different then above

Primary Email to be used for correspondence with the school as well as school newsletters and emergency notifications. *

Secondary Email to be used for correspondence with the school as well as school newsletters and emergency notifications.

Optional Email to be used for correspondence with the school as well as school newsletters and emergency notifications.

Emergency Contact Name *

Relation to student *

Primary # *

Secondary #

Emergency Contact Name

Relation to student *

Primary #

Secondary #

Primary Care Doctor *

Phone # *

Dentist

Phone #

Medical History

List all allergies, including drug, food and environmental.

Student 1

Student 2

Student 3

Student 4

Does student require an Epi-Pen?

Student 1 *

Yes

Student 2

Yes

Student 3

Yes

Student 4

Yes

List all current medications, including medication name, dosage and time given at home?

Student 1

Student 2

Student 3

Student 4

Describe any chronic or reoccurring health conditions such as Asthma and any known triggers.

Student 1

Student 2

Student 3

Student 4

List any operations or serious past injuries.

Student 1

Student 2

Student 3

Student 4

Does student wear glasses or contact lenses?

Student 1

Glasses

Contact Lenses

Student 2

Glasses

Contact Lenses

Student 3

Glasses

Contact Lenses

Student 4

Glasses

Contact Lenses

Does student have hearing problems? Please explain.

Student 1

Student 2

Student 3

Student 4

Date of last Physical Exam?

Student 1 *

Student 2

Student 3

Student 4

This health history is correct so far as I know, and this person herein described has permission to engage in all school activities except as noted below.

Authorization for Treatment: I hereby give permission to the Birches Academy personnel to send my child for emergency room treatment and to call his/her primary physician if necessary. Please type your name in the box below. It will be used as your digital signature of agreement. *

Permissions

Permission to give my child Tylenol/Advil for headache or minor discomfort, if needed. Permission to give antacid, apply Calamine lotion, sting kill swabs, antibiotic ointment, hydrogen peroxide, betadine, or hydrocortisone cream, as needed.

Student 1 *

Yes

Call First

Student 2

Yes

Call First

Student 3

Yes

Call First

Student 4

Yes

Call First

In connection with the educational programs in our school buildings, opportunities may occur to photograph or videotape your child or any artwork they create. These photographs and/or videos may be used in the school, newsletters, school web site, or in local or regional newspapers.

I give my permission for my child to be photographed, videotaped, audio-taped, named or shown on television, named or pictured in a newspaper, and/or appear in a public performance (which may be photographed or videotaped).

Student 1 *

Yes

Student 2

Yes

Student 3

Yes

Student 4

Yes

In order to maintain the communication necessary for a small, learning community, it is helpful to share contact information such as names, addresses, telephone numbers and e-mails. This may be done within classrooms or published as a school directory to be used solely within the school.

I hereby give permission for The Birches Academy to share my contact information with other families in my child’s class or with other parents in The Birches community.

Student 1 *

Yes

Student 2

Yes

Student 3

Yes

Student 4

Yes

I understand and will abide by the above terms and conditions for Internet access at The Birches Academy. I further understand that any violation of the regulations above is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked, school disciplinary action may be taken and/or appropriate legal action.

Student 1 *

Yes

Student 2

Yes

Student 3

Yes

Student 4

Yes

Report abuse