Contact Information |
Child's First Name: |
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Child's Last Name: |
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Date of Birth: |
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Mother's Name: |
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Home Phone: |
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Cell Phone: |
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Email Address: |
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Mother's Address: |
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Mother's Employer: |
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Father's Name: |
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Cell Phone: |
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Father's Address: |
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Father's Employer: |
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Child's Lives With: |
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Legal Guardian(s): |
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| The Child may be released to the person(s) signing this agreement or to the following: |
Full Name: |
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Relationship to Child: |
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Relationship to Guardian/Parent(s): |
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Other Identifying Information: |
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Full Name: |
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Relationship to Child: |
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Relationship to Guardian/Parent(s): |
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Other Identifying Information: |
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Authorized Contact/Release Information |
Persons to contact in the case of emergency when parent or guardian cannot be reached: |
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Phone Number |
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Name: |
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Phone Number: |
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Name: |
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Phone Number: |
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If Transportation is required for before/after school: |
Name of Public/Private School: |
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Illness |
Children who become ill, or retain a temperature of 100 degrees or higher may not remain at school, nor will an ill child be admitted. It is the responsibility of the parent/guardian to make arrangements to have the child picked up as soon as possible after they have been notified. Children who have been exposed to or have contracted serious communicable or infectious diseases may not return to school until the disease is no longer contagious, and a note from the child's physician is given to the Director. |
Medications |
Medication will only be administered in accordance with State Guidelines. Parents will be required to provide a Physician written prescription, including the child's name and dosage. Parents are required to complete and sign a new written authorization form for each week the child is on medication. All medications must remain at the front office and returned home each night. No over the counter medications may be administered without Doctor's written authorization. No medicines may be placed in the child's tote bag.
My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre- existing illness, allergies, diet restrictions, or health concerns: |
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Emergency Medical Authorization
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Child's Doctor Name: |
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Phone Number |
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Child's Dentist Name: |
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Phone Number: |
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Should (child's name)
Date of Birth
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(mm/dd/yyyy) suffer an injury or illness while in the care of Oxford Trail
s Academy and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibility for payment for services. |
PHOTOGRAPHY/VIDEO RELEASE:
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Oxford Trails Academy, licensees, and assignees may use photographs, reproductions, and /or sound recordings of my child, for any and all purposes, which may include promotional/advertising and publicity purposes, without compensation. All negatives positives, prints, or videos shall be the property of Oxford Trails Academy, and they will not identify my child without written consent. I understand that this approval may be revoked at any time by written request to the management. |
I Grant Permission: |
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