Education Safety Policy Form

EDUCATION SAFETY POLICY FORM

School Information

Student Information

Date of Birth:    Student ID:    Grade / Program:

Parent / Guardian Information

Relationship:    Phone:    Email:

Emergency Contacts & Medical Information

Acknowledgment of Safety Policies

I acknowledge that I have received, read, and understand the school's Safety Policies set forth below. By checking each applicable item I confirm that I have reviewed the policy content and accept the obligations and conditions identified.

I acknowledge the Emergency Drills and Evacuation Procedures policy, including the schedule of drills, student responsibilities during drills, and required reunification procedures.

I acknowledge the Emergency Response and Critical Incident policy, including staff authority to enact lockdowns, shelter-in-place, and to coordinate with emergency responders.

I acknowledge the Injury and Illness Reporting policy requiring immediate notification of school health personnel for injuries, documentation of incidents, and parental notification for significant injuries.

I acknowledge the Medication Administration policy and consent to trained personnel administering medication in accordance with written instructions and required authorization forms.

I acknowledge the Transportation Safety policy covering bus conduct, seat assignment, student supervision, and procedures for field trip transport.

I acknowledge the Visitor and Campus Access policy, including check-in procedures, identification requirements, and restricted areas.

I acknowledge the Bullying, Harassment and Threat Assessment policy, including reporting obligations and disciplinary processes.

I acknowledge the Food Allergy and Anaphylaxis Management procedures and will provide necessary medication and written emergency plans if applicable.

I acknowledge Field Trip Safety requirements, including consent to travel, adult supervision ratios, and rules of conduct while off-campus.

I acknowledge Technology and Internet Safety rules, including acceptable use, privacy expectations, and disciplinary action for violations.

I consent to the school's limited use of photographs or video of the student for educational or safety purposes, subject to the school's written media policy. (Check only if you consent.)

Authorizations, Certifications, and Release

By signing below I certify that the information provided on this form is true and accurate to the best of my knowledge. I agree to promptly notify the school of any changes to emergency contacts, health status, or significant behavior issues.

I authorize school personnel to provide or arrange emergency medical treatment for the student if warranted. I further authorize school employees to administer or facilitate administration of prescription medication to the student in accordance with the Medication Administration policy and accompanying written authorization when submitted.

To the maximum extent permitted by law, I release and hold harmless the school, its governing board, employees, volunteers and agents from liability for injury or damage arising from ordinary negligence in the administration of the safety policies, drills, or routine supervision; this release does not apply to acts of gross negligence, willful misconduct, or other liability that cannot be disclaimed by law.

I understand that violations of safety policies may result in disciplinary action and that the school may take reasonable measures to protect the health and safety of students, including temporary exclusion from activities where a health or safety risk exists.

Consent Options (Please select applicable authorizations)

I authorize emergency medical treatment when the parent/guardian cannot be reached.

I authorize administration of prescribed medication in accordance with school policy and provided written orders.

I authorize the student to participate in off-campus activities and to be transported by school-approved vehicles and drivers.

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