Student Emergency Information

"*" indicates required fields

Student Information

First Name*

Middle Name*

Last Name*

Date of Birth

Home Phone

Mobile Phone*

(student's mobile phone number if applicable)

Address

Street Address City State / Province / Region ZIP / Postal Code

Any health conditions we should know about in an emergency?

Other Medical Needs:

Needs EpiPen (Complete EpiPen Packet)

Asthma

Family Doctor's Information

First Name*

Last Name*

Phone*

Address *

Street Address City State / Province / Region ZIP / Postal Code

Mother/Guardian Information

First Name*

Last Name*

Email*

Mobile Phone*

Work Phone*

Address (If Different from Student)

Address

Street Address City State / Province / Region ZIP / Postal Code

Father / Guardian Information

Last Name*

First Name*

Email*

Mobile Phone*

Work Phone

Address (If Different from Student)

Address

Street Address City State / Province / Region ZIP / Postal Code

Name of Local Person to Contact if Parent(s)/Guardian(s) is Not Available

First Name*

Last Name*

Relationship to Student*

Mobile Phone*

Work Phone

Emergency Treatment Statement

If emergency treatment is required, and the parents or legal guardian cannot be reached immediately, your approval by checking the box in the space below empowers Christ Lutheran School authorities to exercise their own judgement in calling the physician indicated above and/or transport the child to a hospital emergency room. Likewise, your approval by checking the box in the space below in not sufficient for the release of confidential information protected by Federal Law.

Agreement*

By checking this box, I (We) agree to the Emergency Treatment Statement given above.

PERMISSION TO PARTICIPATE IN SCHOOL ACTIVITIES AND PERMISSION FOR EMERGENCY MEDICAL PROCEDURES

I hereby grant permission for my child to use all of the play equipment and to participate in all of the activities of the school.

I hereby grant permission for my child to leave the school premises under the supervision of a staff member or authorized adult (aged 21 or older) for neighborhood walks or for field trips in an authorized vehicle.

It is understood that every adult who assists as a driver for field trips or athletic events will have a valid California driver’s license, possess evidence of the legal minimum for insurance, and abide by applicable seat belt regulations.

I hereby grant permission for my child to be included in evaluations and pictures connected with the school program.

I hereby grant permission to the school and/or the agent of the school to administer medicine designated by me on the Request For Medication Form to my child. All medicine must be in the original prescription container, have the child’s name on it, with instructions clearly marked by the pharmacist or physician, and given to the office.

I hereby grant permission to the school and/or the agent of the school to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to, the following:

Attempt to contact a parent and/or guardian.
Attempt to contact the child’s physician.
Attempt to contact a parent and/or guardian through any of the persons listed on the Emergency Information Form.
If we cannot contact a parent and/or guardian or the child’s physician, we will do any or all of the following:
- Call another physician or the paramedics.
- Call an ambulance.
- Have the child taken to an emergency hospital in the company of a staff member
Any expenses incurred under Item 4 above, will be borne by the child’s family.
The school will not be responsible for anything that may happen as a result of false information given at the time of enrollment.

Agreement*

By checking this box, I (We) consent to the Permission to Participate statements and the Emergency Medical Procedures.

PARENT HANDBOOK ACKNOWLEDGEMENT

The Parent Handbook outlines policy and practice at Christ Lutheran School and informs students and parents about what is expected in a variety of situations. Reading this manual and being familiar with its contents is vitally important for the proper functioning of the school and for your understanding of the expectations we have of ourselves as well as that of each family represented. Therefore, we request that you not only carefully read this publication, but that you also check the box indicating that you indeed received a copy of the Parent Handbook.

Acknowledgement*

By checking this box, I (We) acknowledge that I (We) have received a copy of the Parent Handbook