Student Records Student's Name(required) Student's Pronouns (required) Student's Date of Birth(required) Student's Email Parent's Name(required) Parent's Email(required) Parent's Phone(required) Parent's Secondary Phone Parent's Address(required) Parent's Name Parent's Email Parent's Phone Parent's Secondary Phone Parent's Address Contact Info for Additional Parents + Caretakers <3 Emergency Contact Emergency Contact Name and Pronouns(required) Emergency Contact Phone(required) Emergency Contact Relationship to Student(required) Health Information Name of Student's Physician/Clinic Phone Number of Physician/Clinic Address of Physician/Clinic Is there any other health information — including allergies — that we should know about?(required) Yes No Additional Health Information In the event that your child is seriously sick or injured and none of your emergency contacts can be reached, what would you like ALC to do?(required) It is understood that in the final disposition of an emergency case, the judgment of the school will prevail. Your recommendation as indicated on this form will be respected as closely as possible. I agree to the statement above.(required) I understand that by law the ALC must have current immunization records at all times. Upon completing this form, I will provide the ALC with up-to-date immunization records or a letter of medical exemption. I agree(required) Parent Signature: Please type full name to e-sign this form.(required) Parent Signature: Please type full name to e-sign this form. Universal Outings Permission As an authorized Parent or Legal Guardian, I understand that there will frequently be school related field trips supervised by staff, and grant permission for the Student named in this form to accompany their schoolmates on such supervised outings. In addition, I grant permission for unsupervised outings as initialed or specified below for the duration of this current school year. Permission to leave school premises for lunch:(required) Alone With Peers With another student of at least the age specified below With Facilitator Permission to leave school premises anytime:(required) Alone With Peers With another student of at least the age specified below With Facilitator Minimum age of accompanying student, if applicable Please describe any other requirements you have for the above permissions to be granted Please describe any specific additional privileges that you would like to grant at this time I understand that my Student's participating in school programming in person while we navigate the presence of the novel coronavirus in our community is contingent on our following of the school's health and safety protocols, which will follow the directives of the CDC and DOH while planning to protect at risk community members as best we can. This includes but isn't limited to following city regulations on group gatherings, submitting the symptom survey before arrival, keeping sick kids home, and communicating proactively with your group's facilitator if a member of your household is exposed to someone with the virus, becomes symptomatic, or tests positive for the virus. Those who fail to follow safety protocols will be required to attend virtual and distance programming only until the situation can be remedied. (required) Authorizer's E-Signature(required) Date of Authorizer's Signature(required) Authorizer's Phone(required) Submit Δ Share this:TwitterFacebookLike this:Like Loading...
