2009-2010 Emergency Information Form

NOTE: This completed form is due upon acceptance at Grace Lutheran School. It is to be updated yearly and is required
to be on file in the school office before the child can attend school. Be sure to update any changes with the office. Please
complete both sides of form.

NAME OF CHILD: GRADE:

SEX: BIRTHDATE: AGE:

IN CUSTODY OF:

MOTHER: HOME PHONE:

WORK PHONE: CELL OR OTHER PHONE:

E-MAIL ADDRESS: ____________________________________

FATHER: HOME PHONE:

WORK PHONE: CELL OR OTHER PHONE:

E-MAIL ADDRESS: ____________________________________

GUARDIAN: HOME PHONE:

(RELATIONSHIP) WORK PHONE:

INSURANCE INFORMATION:

DOCTOR: DR. PHONE:

HOSPITAL PREFERRED:

EMERGENCY CONTACT AND PHONE:

(Please indicate relationship, i.e. friend, grandparent, babysitter, etc.)

SECOND CONTACTAND PHONE:

(Please indicate relationship)

OUT OF STATE EMERGENCY CONTACT AND PHONE:

(Please indicate relationship)

SPECIAL HEALTH CONCERNS Please list chronic illness, allergy, other conditions such as asthma, diabetes, etc. _______

_______

_______

SPECIAL HEALTH INSTRUCTIONS Please list all current medications and treatments. Also please list any other health

instructions of which school should be aware:

***(Please note that if your child needs to take any medication--prescription or over-the-counter--at school, a signed form must
be on file in the school office. You may request this form in the office. See Parent/Student Handbook for medication policy.)

Please complete both sides of form

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 GRACE LUTHERAN SCHOOL
1815 East 9800 South
Sandy, Utah 84092

PERMISSION TO PARTICIPATE IN SCHOOL ACTIVITIES

AND TO RECEIVE EMERGENCY MEDICAL CARE

I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the school

I hereby grant permission for my child to leave the school premises under the supervision of a staff member for
neighborhood walks or field trips in an authorized vehicle. I understand that advance notice will be given for all field trips,
and a signed permission form must be on file for each trip.

I hereby grant permission for my child to be included in evaluations and pictures connected with the school program.

I hereby grant permission for the staff members to take whatever steps may be necessary to obtain emergency medical care
if warranted. These steps may include, but are not limited to the following:

1. Attempt to contact parent or guardian.

2. Attempt to contact the child’s physician.

3. Attempt to contact the parent through any of the persons listed on the emergency information form.

4. Call emergency personnel (911) or have the child taken to an emergency hospital in the company of a staff member.

5. Any expenses incurred under 4, above, will be borne by the child’s family.

6. The school will not be responsible for anything that may happen as a result of false information given at the time of
enrollment or re-enrollment.

7. The school will not assume responsibility for a child who has not been registered for the current year.

Name of child Grade

Home address (city/state/zip):______________________________________________________

Signed:
(Father/Guardian) Date

Signed:
(Mother/Guardian) Date

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