Student Day Intake Set

STUDENT DAY INTAKE SET

Student Information

Student Name:

Date of Birth:   Student ID:

Primary Phone:   Email:

Parent / Guardian Information

Relationship:   Phone:

Relationship:   Phone:

Emergency Contacts (Other Than Parent/Guardian)

Relation:   Phone:

Relation:   Phone:

Medical Information & Consent

Physician Phone:   Insurance Provider:

I authorize staff to obtain emergency medical care and transport my child to an emergency facility if I cannot be reached. I agree to be financially responsible for such care.

I authorize designated staff to administer medication as prescribed and documented below. Medication must be provided in original containers with written instructions.

EpiPen / injectable medication required: provide device and written emergency protocol

Pickup Authorization

Relation:   Phone:

Relation:   Phone:

Behavioral Supports & Educational Needs

Student has an IEP or 504 plan (provide current plan to program)

Behavior support plan exists and has been provided

Transportation & Attendance

Days Attending: Mon Tue Wed Thu Fri

Typical Arrival Time:   Typical Departure Time:

I consent to program-arranged transportation for field trips and local travel when authorized in writing; I understand separate trip notices will be provided for each event.

Dietary Requirements

Media & Records Release

I authorize use of photographs, video, and audio recordings of my child for educational and program documentation and promotional materials. I understand no personal contact information will be published without additional consent.

I authorize release of educational and health records to the program from prior providers and schools as necessary for service planning. Release is limited to records relevant to care and instruction.

Acknowledgements, Certifications, and Liability

By signing below, I certify that the information provided in this intake form is true and complete to the best of my knowledge. I agree to notify the program promptly of any changes in medical condition, medication, emergency contacts, or custody arrangements.

I authorize program staff to provide routine care and to seek emergency medical treatment for my child when necessary. I release and hold harmless the program, its employees, volunteers, and agents from liability for ordinary negligence in connection with the provision of care, except for willful or grossly negligent acts.

I understand that medication will only be administered in accordance with written instructions from a licensed prescriber and that I am responsible for providing medication in original containers. I agree to indemnify the program for claims arising from knowingly providing false medical or allergy information.

Program Enrollment Details (for office use)

Program Start Date:   Assigned Group / Room:

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