Name:
Mother's First and Last Name
Email:
Cell Phone Number:
Street Address, City, State, ZIp:
Emergency Contact Name:
Emergency Contact Phone #:
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child (children) is in good health. I assume all responsibility for the health of my child (children). EMERGENCY MEDICAL TREATMENT In the event of an emergency, I hereby give permission to transport my child (children) to the hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. PLEASE USE THE BOX BELOW TO SIGN AND DATE!!!!!!! Type Signature & Date in this space:
In case of emergency if you are unable to reach me, please contact:
Relationship:
Phone Number:
Primary Care Name:
Health Plan Carrier and Policy #:
CODE OF CONDUCT – Grades 1-12 1. Students are expected to behave in a responsible manner, demonstrating courtesy and respect for other students, teachers, volunteers, and property at all times. 2. Students should respect the classroom as a place of learning. 3. Cell phones and other electronic devices are discouraged from being brought into the classroom. If a student does carry a phone, they must turn it off during class time. The instructor may confiscate the device for the remainder of the class, if it becomes a distraction. 4. Bullying will not be tolerated. 5. No student is allowed to leave the premises (defined as the area in which the activity is taking place) without the permission of the teacher or coordinator. 6. The use of drugs, tobacco, alcohol, fireworks, lighters or items that endanger people or property are strictly forbidden. 7. Clothing must be appropriate 8. Language and behavior should exemplify Christian values. 9. Students are not allowed to wait for pick up in or around the parking lot. Parent I agree that my child (or children) is/are expected to abide by the above Code of Conduct. I agree that if my child (or children) fail to abide by this Code or engage in any infraction that is deemed by the Coordinator to be inappropriate, he/she may be dismissed and sent home, or I may be required to attend class with him/her. PLEASE USE THE BOX BELOW TO SIGN AND DATE THE ABOVE INFO!!!! Type Signature & Date in this space:
Child #1 First and Last Name:
Child #1 Gender:
Child #1 Birthdate:
Child's school grade for the upcoming/current school year:
Name of school child attends:
Please indicate any physical restrictions, dietary needs, medications, allergies, or special medical conditions below:
Any other information you would like us to know?
Child #2 First and Last Name:
Child #2 Gender:
Child #2 Birthdate:
Child's school grade for the upcoming/current school year:
Name of school child attends:
Please indicate any physical restrictions, dietary needs, medications, allergies, or special medical conditions below:
Any other information you would like us to know?
Child #3 First and Last Name:
Child #3 Gender:
Child #3 Birthdate:
Child's school grade for the upcoming/current school year:
Name of school child attends:
Please indicate any physical restrictions, dietary needs, medications, allergies, or special medical conditions below:
Any other information you would like us to know?
Child #4 First and Last Name:
Child #4 Gender:
Child #4 Birthdate:
Child's school grade for the upcoming/current school year:
Name of school child attends:
Please indicate any physical restrictions, dietary needs, medications, allergies, or special medical conditions below:
Any other information you would like us to know?
Child #5 First and Last Name:
Child #5 Gender:
Child #5 Birthdate:
Child's school grade for the upcoming/current school year:
Name of school child attends:
Please indicate any physical restrictions, dietary needs, medications, allergies, or special medical conditions below:
Any other information you would like us to know?
