Christian Community Schools
EMERGENCY INFORMATION: School Year: ______
Last Name First Middle Phone
______
Home Address City State Zip
______
Mailing Address City State Zip
______
Father or Guardian (Full Name) Employer Day Phone/ Cell Phone
______
Mother or Guardian (Full Name) Employer Day Phone/ Cell Phone
OTHER PERSONS TO CALL IF PARENT/GUARDIAN CANNOT BE REACHED:
Name ______Relationship ______Phone: ______
Name ______Relationship ______Phone: ______
Physician: ______Phone: ______
Dentist: ______Phone: ______
Preferred Hospital: ______Ins. ______
May we contact any available physician/ dentist/ hospital? ______Yes ______No
Special Medical Conditions/ Allergies: ______
Other Medical Conditions: ______
My student has permission to take: TYLENOL _____ IBUPROFEN _____ MIDOL ______
All medications must be clearly labeled with the student’s name, medication name, dosage, how often it is taken, and why they take the medication. All medications must be within current date. No expired meds will be accepted. Inhalers must have written instruction on how the doctor prescribes the inhaler to be used.
I hereby give my consent for my student to receive emergency medical treatment, should a serious illness or an accident occur, as may be considered necessary in the opinion of the attending physician or dentist. I understand that I am responsible for any medical or miscellaneous expenses that may occur from treatment required. I also will provide proof of current immunizations.
______Parent/ Guardian Signature ______Date
OFF CAMPUS FORM
I ______(name) being the parent or guardian of ______(student’s name) give my permission for my student to leave school grounds during school hours for various approved activities ______(initial) and lunch ______(initial). Should an accident or illness occur, permission is granted to obtain the necessary medical care. ______
Print Name of Parent or Guardian Signature Date
This form shall remain on file and in force for the ______school year.
Christian Community Schools
Student Name ______
Driver’s Registration
Make & Model of Car ______Year ______Color ______License Plate ______Expiration ______
Driver’s License Number ______Expiration ______
Insurance Policy Number ______Expiration ______
Parent’s Comments or Restrictions:
We understand that driving on campus is a privilege and promise to obey the rules. We understand that failure to do so may result in driving privileges being suspended.
______Parent Signature ______Date
______Student Signature ______Date
“Permission to Ride”
______(student’s name) has my permission to ride with the following student drivers:
______
______
______
______
______
This may include to and from school, off campus during lunch, and approved activities.
Parent’s comments or restrictions:
______
______Parent’s Signature ______Date