Pinecrest Medical / Emergency Care Form

-Pinecrest School is required by the Commonwealth of Virginia Department of Social Services to collect ALL of this information for all students and campers.
-Please respond with accurate information.
-Please have all information ready at hand to complete all spaces on this form before beginning. 
-No space can be left blank.
-Please type N/A if not applicable. 
-If this information is not on file for a child, s/he will not be permitted to attend school or camp. 
-Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 
-Once you click "Submit," the form is no longer accessible to you and cannot be edited. If information is left blank or is inaccurate at this point, you will incur the charge(s) listed above. 
 


Child

Please type N/A if not applicable. Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 


Parents/Guardians

Please type N/A if not applicable. Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 
 
Parent/guardian listed as Parent/Guardian 1 will be contacted first should any needs arise.  


Emergency Contacts AFTER Parents/Guardians

Please type N/A if not applicable. Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 
By listing someone as an Emergency Contact, you are also authorizing that person to pick up your child from Pinecrest School. 


Pick-up Authorizations

Please type N/A if not applicable. Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 

Medical Information

Please type N/A if not applicable. Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 

Doctor/Insurance Information

Please type N/A if not applicable. Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 

Past School Information

Please type N/A if not applicable. Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 

Permissions

Please type N/A if not applicable. Families will incur a $5/field fee for each field left blank or completed with inaccurate information (i.e., typing a phone number or zip code with all 0s). 
Photos and videos are taken regularly at Pinecrest. I understand that with the completion and submission of this form to Pinecrest School that my child’s photo and/or video will be shared with the Pinecrest community and could be used in school or camp brochures, ads, media coverage, on the school website, on the school's social media sites, et cetera. Names are never used with student photos or videos. Concerns about this should be addressed directly with the Head of School.
 
Pinecrest School does not share families’ contact information with third parties.

Parent/Guardian Agreement

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