Educational Supplemental Packet

Educational Supplemental Packet

Student Information

Student Full Legal Name:

Parent / Guardian Information

Emergency Contacts

Medical Information & Authorization

Primary Care Physician:  Phone:

Authorization for Emergency Treatment: By checking the box below, I authorize school personnel and designated medical professionals to provide and consent to medical treatment, including hospitalization, diagnostic procedures and emergency care, if deemed necessary by medical personnel when I cannot be reached.

I authorize emergency medical treatment and transport as necessary.

Medication Administration: I authorize school staff to administer medication to my child in accordance with written instructions provided by the prescribing clinician and school medication policy. I understand medication must be supplied in original containers and accompanied by clinician instructions where applicable.

I consent to school administration of prescription medication per written instructions.

Dietary Restrictions & Special Needs

Student has an active IEP    Student has an active 504 plan    Student requires other documented accommodations

Field Trip & Transportation Consent

I understand field trips are part of the educational program. Transportation may be by school bus, contracted carrier, or other school-approved vehicle. I acknowledge participation is subject to school rules and supervision.

I consent to my child's participation in school-sponsored field trips and authorize school-provided transportation.
I do not consent to field trip participation at this time.

Media Release & Directory Information

The school may photograph, record, or publish student work for school publications, educational materials and school communications. Directory information may include name, grade, school, and participation in officially recognized activities.

I grant permission for my child's image or work to be used for general school purposes.
I do not grant permission for media use of my child's image or work.

I permit disclosure of directory information as permitted by school policy.
I do not permit disclosure of directory information.

Technology Acceptable Use & Academic Policies

By checking the box below, I acknowledge receipt of the school's technology acceptable use expectations and academic policies, and I understand violations may result in restricted access and disciplinary action.

I acknowledge and accept the Technology Acceptable Use Policy and school academic policies.

Attendance & Conduct: I understand attendance, punctuality and compliance with the student code of conduct are required. I agree to supply accurate records and timely notifications for absences.

I acknowledge and accept the attendance and conduct policies.

Acknowledgment & Certification

I certify that all information provided in this supplemental packet is true and complete to the best of my knowledge. I understand that falsification or omission of material information may result in withdrawal of enrollment or other administrative action. I understand that I may revoke any consent provided herein by written notice to the school, except to the extent the school has already relied upon the consent.

Liability and Indemnification: To the fullest extent permitted by law, I release the school, its employees, agents and volunteers from liability for ordinary negligence in providing supervision and consent to the authorizations above, and agree to indemnify and hold them harmless for claims arising from services provided consistent with this document, except for willful misconduct or gross negligence.

Optional Additional Information

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