Additional student information 2010-1

Additional Student Information 2013-14
Student Name (print legibly): ___________________________________________
I give my permission for my child to attend all school field trips: _____ Yes _____ No My child may use the internet as needed for curriculum under strict supervision of teaching staff: _____ Yes _____ No I give my permission for my child to be interviewed and/or photographed by the school paper, yearbook or local media newspaper. _____ Yes _____ No I give permission for my child to have his/her photo displayed on the Clarke Community School’s web page at the discretion of the principal. _____ Yes _____ No Migrant: Migrant is defined as having moved in or out of the state within the last three years to find
employment in agriculture on a seasonal or temporary basis. Examples are meatpacking, crop field work, vegetable canning. _____ Yes _____ No
Student Health Information:
1. Health Concerns (please circle all that applies): diabetes, epilepsy/seizures, cancer, orthopedic problems, scoliosis, asthma, blood disorder, headaches, hepatitis, heart problems, other ______________________________________________________________________________ 2. Allergies: If your child has environmental, food or medication allergies, please list. Also if your child is allergic to insect stings list and the treatment to the stings. 3. Vision: Student wears (glasses, contacts, both, none): ___________________________________ 4. Hearing: Does student have a hearing problem and/or use hearing aids or hearing devices? If yes, explain:________________________________________________________________________ 5. Report of past year: Has this student had any accidents, injuries, surgeries or serious illnesses since the beginning of last year that we need to be aware of? ______________________________ ______________________________________________________________________________ 6. Immunizations received since last school year? Date of last tetanus booster: (type, date, and Dr. or clinic) __________________________________________________________________ 7. Permission to give Tylenol at school: My student may be given: Tylenol if needed ____ Yes ____ No or Ibuprofen if needed ____ Yes ____ No Please check the following medication, if allowed to be dispensed by the nurse or qualified staff. _____ Cough drop/throat lozenge _____ Decongestant (similar to Tylenol Sinus) (all medications given would be dosed age/weight appropriately). Any medication that is not indicted as ok to give will not be given to the student without permission prior to administration. 8. Family Doctor and Phone: _________________________________________________________ 9. Family Dentist and Phone: _________________________________________________________ O:\VSS\VICKY\Registration\Registration Forms 1314\Additional Student Information 1314.docx 10. Audiologists and audiometerists from the Area Education Agency (AEA) will be working in our schools this year screening students for hearing problems and conduction screening evaluations. This is being done, as in past years, to identify students that have hearing losses or problems of educational or medical significance. Parents will be notified of the test results. Does the school have permission to do these tests? _______ Yes ______ No Family Data:
Parent Marital Status (circle one): Married Divorced Separated Single Deceased Are there custody papers on file and has the school been given a copy of the custody papers? _____ Yes _____ No Is there any visitation rights? _____ Yes _____ No Student Insurance (K-12) – Please mark one of the following two statements:
_____ 1. We have adequate insurance to protect our son/daughter in case of an accident. _____ 2. I am insuring my child under the STUDENT ASSURANCE SERVICE, INC. (forms will be available at registration or in school offices)
By signing this form I understand this consent will be used only in an emergency situation. Every effort will be made to contact the parent/guardian. I give permission for the staff of Clarke Community Schools to utilize the services of the local ambulance, the local hospital, and the doctor on emergency call for emergency treatment of my child. I will be responsible for charges involved. ______________________________________________ _______________________ Emergency contact 1 (Name and phone #) __________________________________________ Emergency contact 2 (Name and phone #) __________________________________________ COMPLETE ONLY FOR 7-12 ATHLETES/EXTRA CURRICULAR ACTIVITIES:
I/We understand that accidents may occur in athletics/extra curricular activities even though normal safety precautions have been taken. My child has permission to practice and compete in the interscholastic program. _____ Yes _____ No Parent/Guardian Signature: ______________________________________ Parent/Guardian Printed Name: ________________________________________________________ Note: Information from this form may be shared with staff members involved with the student while at school. O:\VSS\VICKY\Registration\Registration Forms 1314\Additional Student Information 1314.docx


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