Please fill out the form below to the best of your ability.

Father's Information

Other HouseHold Member 1

Other Household Member 2

**If your child is on the McKay Scholarship, please supply the social security number of the parent listed on the application:

Additional Pick Up 1

Additional Pick Up 2

Additional Pick Up 3

Secondary Emergency Contact (Other than parents or guardian)

**All students are required to have below documents on file before they can start school** Current Immunization Form (DH 680) and Physical (DH3040)

Gracepointe doesn’t provide any medication to students other than what is sent by the guardian for the student. All prescription drugs must be in the prescription package when brought to the office. There must be clear direction on the bottle for the staff to follow. All over the counter medication must be in original packaging and have the students name on it.

By signing this you are giving the Staff of Gracepointe permission to administer above medications and will in no way hold Gracepointe staff responsible for the distribution of said provided medication.

I___________, hereby give permission for my child, _______________ to be given emergency treatment, to include first aid and CPR by a qualified staff member of Gracepointe. I further authorize and consent to medical, surgical, and hospital care, treatment, and procedures to be performed for my child by his/her regular physician, or when the physician cannot be reached, by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard my child's health if I cannot be contacted. In such case, I waive my right of informed consent to such treatment. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further authorize said center to take my child to a hospital and agree that I will pay all physician and hospital bills and said center will not be responsible for them.