Pinecrest Medical / Emergency Care Form

-Pinecrest School is required by the Commonwealth of Virginia Department of Education/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).

Child Full First, Middle, Last Name *

First Name Child Should Be Called at Pinecrest *

Child Last Name *

Gender *

Child Date of Birth (_ _ month / _ _ day / _ _ _ _ year) *

Child Street Address *

Child City *

Child State *

Child Zip Code *

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.

Parent/Guardian 1 First & Last Name *

Relationship *

Parent/Guardian 1 lives at the same address as the child. *

Parent/Guardian 1 Street Address, City, State & Zip Code if different from Child's Address Entered Above

Parent/Guardian 1 Home Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Parent/Guardian 1 Work Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Parent/Guardian 1 Mobile Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Parent/Guardian 1 Preferred Phone Number To Call First *

Parent/Guardian 1 Email Address *

Parent/Guardian 1 Employer Name *

Parent/Guardian 1 Employer Street Address, City, State, Zip Code *

Parent/Guardian 2 First & Last Name *

Relationship *

Parent/Guardian 2 lives at the same address as the child. *

Parent/Guardian 2 Street Address, City, State & Zip Code if different from Child's Address Entered Above

Parent/Guardian 2 Home Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Parent/Guardian 2 Work Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Parent/Guardian 2 Mobile Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Parent/Guardian 2 Preferred Phone Number To Call First *

Parent/Guardian 2 Email Address *

Parent/Guardian 2 Employer Name *

Parent/Guardian 2 Employer Street Address, City, State, Zip Code *

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, I am also authorizing that person to pick up my child from Pinecrest School. *

Emergency Contact 1 First & Last Name *

Relationship *

Emergency Contact 1 Home Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Emergency Contact 1 Work Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Emergency Contact 1 Mobile Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Emergency Contact 1 Preferred Phone Number To Call First *

Emergency Contact 1 Street Address, City, State, Zip Code *

Emergency Contact 2 First & Last Name *

Relationship *

Emergency Contact 2 Home Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Emergency Contact 2 Work Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Emergency Contact 2 Mobile Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Emergency Contact 2 Preferred Phone Number To Call First *

Emergency Contact 2 Street Address, City, State, Zip Code *

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).

Reminder: Those listed above as Emergency Contacts are authorized to pick up your child from Pinecrest School.

First & Last Name(s) of Person(s) Authorized to Pick Up Child *

First & Last Name(s) of Person(s) NOT Authorized to Pick Up Child *

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).

If a student is experiencing a fever (recognized by the school as 100 or higher) or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea and/or is otherwise unwell, that student should not come to school unless the cause is allergies or another condition identified by the family and/or doctor on the student’s 2022-23 Pinecrest online medical/emergency form and/or their Virginia school entrance health form. Students must be fever-free, vomit-free, and/or diarrhea-free for 24 hours before returning to school. *

Diseases (i.e., asthma, diabetes, seizures, et cetera) - please be specific and separate each item by commas *

Conditions (i.e., ADD, ADHD, neurodiversity, cardiac anomalies, depression, anxiety, et cetera) - this is the time to note anything about your child, their behavior, and/or any diagnoses that will help the teachers and staff best support them at Pinecrest - please be specific and separate each item by commas *

Allergies (drug, food, et cetera), Food Intolerances and/or Food Restrictions (for religious or other reasons) - please be specific and separate each item by commas. If food allergy, please include reaction and indicate if reaction can be triggered through ingestion, touch, and/or inhalation. *

Action Pinecrest Should Take if Child is Exposed to Allergen - please be specific and separate each item by commas *

Name / Type of Medication Taken Regularly - please be specific and separate each item by commas *

Other Pertinent Development or Medical Information or Special Accommodations Needed - please be specific and separate each item by commas *

My child must wear a face mask at Pinecrest School inside. *

My child must wear a face mask at Pinecrest School outside. *

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).

Doctor Name *

Doctor Phone Number (_ _ _ - _ _ _ - _ _ _ _) *

Do you have insurance? *

Insurance Company *

Insurance Policy Number *

Is pre-certification required? *

Other Important Information on Insurance Card or About Insurance Policy *

Name of Person Responsible for Medical Expenses *

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).

Name(s) of Previous School(s) or Daycare(s) Attended *

Name(s) of Other School(s) or Daycare(s) Currently Attending & Grade Level *

Permissions

I give permission for my child to ride on buses or vehicles contracted by Pinecrest School for field trips. *

I give permission for my child to ride in personal vehicles driven by staff for field trips. *

I give permission for my child to ride in personal vehicles driven by parents/guardians for field trips. *

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

Parents/guardians must keep their child home from Pinecrest when ill. Pinecrest School agrees to notify at least one parent/guardian whenever the child becomes ill while at Pinecrest, and the parents/guardians agree to make arrangements to pick the child up as soon as possible. Parents/guardians must inform Pinecrest School within 24 hours or the next business day if their child or any member of their immediate household has developed any reportable communicable disease. Cases of COVID-19 and/or life-threatening diseases must be reported immediately following school protocols. *

Parents/guardians authorize Pinecrest School to obtain immediate medical care if any emergency occurs when they cannot be located immediately and, if necessary, to transport the child to the appropriate medical facility. Parents/guardians authorize Pinecrest School to release any and all medical information provided on this medical/emergency care form to medical personnel in case of an emergency. The hospital/medical staff is authorized to provide any treatment deemed necessary for the well being of the child. *

Type Name for Parent/Guardian Signature *

Today's Date * +