Child’s Name:
DOB:
Authorization for Emergency Medical Attention, Emergency Contacts & Medical Information
2015 Summer / 2015-16 School Year
Please complete these forms online using Adobe Reader, and then print and sign them. You may also print a blank copy
and complete it by hand. Note that you cannot save a filled-out version of this form. Please return a hard copy or email a
scan of this packet to Angela Burris, Parish School Nurse, [email protected].
Childʼs Full Name:
Childʼs Primary Address:
Street
City
Motherʼs Full Name:
State
Zip
DOB:
Primary E-mail Address:
Cell:
Home:
Work:
Fatherʼs Full Name:
DOB:
Primary E-mail Address:
Cell:
Home:
Work:
It is required to list two (2) persons The Parish School may contact (other than a parent) in the event the staff
cannot reach you and to whom you give permission to pick up your child:
Contact 1:
DL # & State:
Phone:
Relationship:
Contact 2:
DL # & State:
Phone:
Relationship:
In the event that I/we cannot be reached to make arrangements for emergency medical attention, I/we authorize a designated
Parish School staff member to contact EMS to take my/our child to the nearest hospital or to the following:
Child’s Physician:
Phone:
Address:
We give our consent for any and all necessary treatment.
Motherʼs/Legal Guardian 1’s Name
Motherʼs/Legal Guardian 1’s Signature
Date
Fatherʼs/Legal Guardian 2’s Name
Fatherʼs/Legal Guardian 2’s Signature
Date
Revised 5/7/15
Form A-1 – Contact and Medical Form
Child’s Name:
DOB:
Authorization for Emergency Medical Attention, Emergency Contacts & Medical Information
2015 Summer / 2015-16 School Year
I/we give permission for The Parish School to administer the following over-the-counter medications (or
their generic equivalent) to my/our child if necessary. Dosages will be administered according to package
directions:
☐ Advil or Motrin (Ibuprofen)
☐ Aleve (Naproxen Sodium)
☐ Benadryl
☐ Topical Benadryl
☐ Calamine Lotion
☐ Cough Drops
☐ Hydrocortisone Cream
☐ Insect Repellant – must be nonaerosol and provided by parent
☐ Midol/Pamprin
☐ Sunscreen – must be non-aerosol
and provided by parent
☐ Throat Lozenges
☐ Tylenol (Acetaminophen)
My/our child has the following medical concerns:
Chronic Medical Conditions:
Allergies:
Dietary Restrictions (i.e. Gluten/Casein Free:
My/our child takes the following medications regularly. (Include prescription, over-the-counter
medications, and supplements. Please keep the school updated on any changes - See Pages 7 and 8.)
Medication
Revised 5/7/15
Dosage
Form A-2 – Contact and Medical Form
Child’s Name:
DOB:
Demographic Form
2015 Summer / 2015-16 School Year
Childʼs Full Name:
Sex: ☐ Male ☐ Female Languages Spoken at Home:
Ethnicity: ☐ Asian/Pacific Islander ☐ Black ☐ Hispanic ☐ Native American ☐ White ☐ Other
Childʼs Primary Address:
Street
City
State
Zip
State
Zip
Child’s Home School District:
Who initially referred your family to The Parish School?
Mother’s Information:
Motherʼs Full Name:
DOB:
Primary E-mail Address:
Cell:
Home:
Home Address:
(if different)
Work:
Street
Ethnicity: ☐ Asian/Pacific Islander
City
☐ Black ☐ Hispanic ☐ Native American
☐ White ☐ Other
Marital Status: ☐ Married to Child’s Father ☐ Single ☐ Divorced ☐ Remarried ☐ Widowed ☐ Partnered
Occupation:
Work Address:
Employer:
Street
City
State
Zip
Education: ☐ High School ☐ Some college ☐ Bachelor’s degree ☐ Master’s degree ☐ Doctorate
Father’s Information:
Fatherʼs Full Name:
DOB:
Primary E-mail Address:
Cell:
Home Address:
(if different)
Home:
Work:
Street
Ethnicity: ☐ Asian/Pacific Islander
☐ Black
City
☐ Hispanic
☐ Native American
State
☐ White
Zip
☐ Other
Marital Status: ☐ Married to Child’s Mother ☐ Single ☐ Divorced ☐ Remarried ☐ Widowed ☐ Partnered
Revised 5/7/15
Demographic-1
Child’s Name:
DOB:
Demographic Form, continued
2015 Summer / 2015-16 School Year
Father’s Information, Continued:
Occupation:
Work Address:
Employer:
Street
City
State
Zip
Education: ☐ High School ☐ Some college ☐ Bachelor’s degree ☐ Master’s degree ☐ Doctorate
Maternal Grandmother’s Name:
Home Address:
Street
E-mail Address:
City
State
Zip
City
State
Zip
City
State
Zip
City
State
Zip
Phone:
Maternal Grandfather’s Name:
Home Address:
(if different)
Street
E-mail Address:
Phone:
Paternal Grandmother’s Name:
Home Address:
Street
E-mail Address:
Phone:
Paternal Grandfather’s Name:
Home Address:
(if different)
E-mail Address:
Street
Phone:
The Parish School does not discriminate based on race, color, national, religious, or ethnic origin.
Revised 5/7/15
Demographic-2
Child’s Name:
DOB:
Physician’s Report & Immunization Record
2015 Summer / 2015-16 School Year
Required as you receive reports and immunizations with child’s annual check-up.
The above named child is entering The Parish School. This statement certifies that in the physician’s
professional opinion, the above named child is physically able to participate in the daily program and
group activities, and s/he is free from communicable diseases.
Date of last exam:
Any special problems or concerns noted in above exam:
Comments:
Immunization Information: Please attach a copy of this child’s immunization record, which will serve as
a true and correct copy of the immunizations received. If your child has an exemption, please turn in the
original document – no copies permitted.
Physician’s Name
Physician’s Signature
Date
Physician’s Address
Physician’s Phone Number
Physician’s Fax Number
This form must be returned to The Parish School on or before the first day of school
in order for your child to attend class.
Revised 5/7/15
Form B – Physician’s Report and Immunization Record
Child’s Name:
DOB:
Authorization for Request and/or Release of Information
2015 Summer / 2015-16 School Year
I hereby authorize The Parish School to request and/or release information that may be helpful in
providing services for my child.
Below are the persons, agencies and schools that The Parish School may contact:
NAME
ADDRESS
TELEPHONE
I understand any information released is strictly confidential and privileged. A copy of this document is as
valid as the original.
Motherʼs/Legal Guardian 1’s Name
Motherʼs/Legal Guardian 1’s Signature
Date
Fatherʼs/Legal Guardian 2’s Name
Fatherʼs/Legal Guardian 2’s Signature
Date
Revised 5/7/15
Form E – Release of Information
Child’s Name:
DOB:
Medication Form/Physician Instructions
2015 Summer / 2015-16 School Year
Complete and return only when/if your child needs medication during school hours.
A separate form is required for each medication.
To be Completed by Parent:
Name of Medication
I/we hereby give permission to The Parish School to dispense the above medication and, if applicable, for
the physician listed below to exchange information about my/our child with The Parish School staff.
Motherʼs/Legal Guardian 1’s Name
Motherʼs/Legal Guardian 1’s Signature
Date
Fatherʼs/Legal Guardian 2’s Name
Fatherʼs/Legal Guardian 2’s Signature
Date
To be Completed by Physician:
Medication
Dosage
Reason for Medication
Desired Effects
Possible Side Effects or Contraindications
Administration beginning and ending dates
to
Are behavioral or performance observations necessary by the teacher?
☐ YES
☐ NO
Best time for physician to be contacted:
Prescribing Physician’s Name
Physician’s Address
Prescribing Physician’s Signature
Phone Number
Date
Fax Number
Please return this form to The Parish School ASAP to begin any new treatment, even if form must
be initially submitted without a prescribing physician’s signature. Please submit completed form
with all signatures as soon as possible.
Revised 5/7/15
Form F – Medication Form
Child’s Name:
DOB:
Parental Permission to Administer Medication
2015 Summer / 2015-16 School Year
Complete and return only when/if your child needs medication during school hours.
A separate form is required for each medication.
Medication
Dosage
Administration beginning and ending dates
Day
to
Morning dose to be administered at:
Afternoon dose to be administered at:
Monday
Tuesday
Wednesday
Thursday
No medication administered after
12:00 p.m. on Fridays.
Friday
If applicable: Prescribing Physician’s Name
Phone Number
Fax Number
I/we hereby give permission to The Parish School to dispense the above medication and, if applicable, for
the physician listed above to exchange information about my/our child with The Parish School staff.
Motherʼs/Legal Guardian 1’s Name
Motherʼs/Legal Guardian 1’s Signature
Date
Fatherʼs/Legal Guardian 2’s Name
Fatherʼs/Legal Guardian 2’s Signature
Date
Please return this form to The Parish School ASAP to begin any new treatment.
Revised 5/7/15
Form G – Parental Permission for Medication
Child’s Name:
DOB:
General Permissions and Release Form
2015 Summer / 2015-16 School Year
☐ Yes ☐ No I/we hereby give permission to The Parish School for my/our child to participate in
supervised water activities. No commercial pools are involved. Sprinklers, water hoses,
and portable wading pools may be used.
☐ Yes ☐ No I/we hereby give consent for The Parish School to provide transportation for my/our
child on planned field trips away from The Parish School campus. I/we do hereby release
and hold harmless The Parish School and all individuals participating in the field or
planned trips from all damages that may be suffered by the participant due to injuries
resulting from the participation of said minor child in field trips. I/we agree(s) not to make
a claim to enter suit against this school or individuals participating therein for any injuries
sustained to said child.
☐ Yes ☐ No I understand that children and their likenesses are never identified by first or last name in
any public communication, including social media. I hereby give permission to The Parish
School to use my child’s photo/video for communications and publicity purposes,
including but not limited to print publications, the school website, and school social media.
Motherʼs/Legal Guardian 1’s Name
Motherʼs/Legal Guardian 1’s Signature
Date
Fatherʼs/Legal Guardian 2’s Name
Fatherʼs/Legal Guardian 2’s Signature
Date
Revised 5/7/15
Form H – General Permissions
Child’s Name:
DOB:
Consent for Treatment
2015 Summer / 2015-16 School Year
I/we hereby give consent for the above named child and/or myself to receive services through
The Parish School and affiliated staff from The Carruth Center at The Parish School – joint referenced as
The Parish School campus throughout. These services could include diagnostics, consultations,
observations, treatment and feedback for Speech-Language, Occupational, and Psychological/Mental
Health therapies.
This consent is given until I/we give notice that these services are no longer requested or until
The Parish School campus professionals notify me these services will no longer be provided. I/we certify
that I/we have legal responsibility for this child and am authorized to consent to treatment for him/her.
I/we understand that all information provided to The Parish School campus professionals is confidential
and will be released to others only with my/our written consent. I/we understand that The Parish School
campus professionals are required to disclose confidential information without my consent in certain
circumstances. These circumstances include, but are not limited to, 1) if it is determined there is a
probability of imminent physical injury by my child to himself/herself or other(s), or if there is a
probability of immediate mental or emotional injury to my child; 2) if the disclosure is required or
authorized by law, legal proceedings, or court order; 3) qualified individuals, corporations, or governmental
agencies involved in paying or collecting fees for mental or emotional health services for my/our child; 4)
other professionals and personnel, under the direction of Parish School campus professionals, who
participate in the diagnosis, evaluation, or treatment of my/our child; 5) a judicial or administrative
proceeding brought against The Parish School campus professionals by myself or my/our child; and 6) the
event it is believed my/our child is the victim of physical abuse, sexual abuse, or neglect, or if my/our
child divulges information about the physical abuse, sexual abuse, or neglect of a child, elder, or disabled
person. The professionals rendering services through The Parish School and affiliated Carruth Center
program are dedicated to using established and empirically supported psychological, behavioral, language,
developmental, and educational evaluation and intervention procedures to optimize the social, emotional,
and cognitive development of each child. In the event a child presents as an immediate danger to
himself/herself, others, or property, the least restrictive intervention shall be utilized to provide safety for
the child, others, or property. While verbal mediation will be the primary intervention utilized, at times
physical contact may be required to provide safety for the child, others, or property.
My/our signature on this document indicates I/we have read the above information and have a clear
understanding of the procedures, policies, and therapeutic interventions described. I/we have been given
the opportunity to have my questions answered regarding the above-described information. I understand
that I/we have the right to withdraw treatment for my/our child at any time.
Motherʼs/Legal Guardian 1’s Name
Motherʼs/Legal Guardian 1’s Signature
Date
Fatherʼs/Legal Guardian 2’s Name
Fatherʼs/Legal Guardian 2’s Signature
Date
Revised 5/7/15
Form I – Consent for Treatment