Permission Form for 2022-2023

Parent Email *

NOTE: If you have more than one child, please submit this form for ONLY ONE of your children. After you submit the form once, there will be a link to add more children. You will NOT have to re-enter your contact & emergency information if you use this link.

Student Information

Student Name *

First Name Last Name

Birth Date

Month Day Year

Student Cell Phone Number

Area Code Phone Number

Grade for 2022-2023 *

Emergency Contact Information

1st Contact *

First Name Last Name

1st Relationship *

1st Preferred Number *

Area Code Phone Number

1st Secondary Number

Area Code Phone Number

2nd Contact *

First Name Last Name

2nd Relationship *

2nd Preferred Number *

Area Code Phone Number

2nd Secondary Number

Area Code Phone Number

3rd Contact

First Name Last Name

3rd Relationship

3rd Preferred Number

Area Code Phone Number

3rd Secondary Number

Area Code Phone Number

Medical Emergency Information

This information will be kept confidential.

Does your daughter have any health conditions? *

Yes No

Please explain what the condition is (include any chronic illness or physical limitation):

Does your daughter have any food or drug allergies? *

Yes No

Please list:

Does your daughter take any medications regularly? *

Yes No

Please select which of the following medications may be administered by office staff to your daughter in case of emergency: *

Tylenol Motrin Benadryl None of the above

Health Insurance Verification

Insurance Coverage *

I verify that my daughter currently has health insurance coverage I verify that my daughter DOES NOT have health insurance coverage

Health Insurance Card - provide information for ALL policies

I will scan & upload a copy of my card below I will bring my insurance card to TEMIMA to be scanned

Upload Health Insurance card

Upload File(s)

Medical Release

By signing below, I hereby give parental permission to Temima, The Richard & Jean Katz High School for Girls, Inc. (hereinafter “TEMIMA”) to act “in loco parentis” in case of medical emergency.

Immunizations

TEMIMA requires that all students have a completed GA. Certificate of Immunization Form (3231) within 90 days of the start of the 2022-2023 school year on file in the school office. TEMIMA does not accept religious exemptions for immunizations.

COVID-19 Waiver and Indemnification Agreement

I understand that my child/ward being an enrolled student, a student applicant, or a minor alumnus (collectively herein, “Student”) is regularly required at times to regularly interact with TEMIMA teachers, administrators, employees, school guests, and independent contractors, as well as other students at the TEMIMA’s facilities, or on school trips, or at some other public or private locations.

In consideration of my Student’s enrollment or continued enrollment by TEMIMA, I hereby agree as follows:

1. In the event that in the course of my relationship with TEMIMA, I or my Student become exposed to, or positively, contract the Coronavirus, I hereby agree that I will not (nor will I permit my Student or anyone on his/her behalf) file any claim, action, or lawsuit whatsoever with any federal, state, or local court, government agency, or alternative dispute resolution organization alleging that my (or my Student’s) exposure to or contracting of the Coronavirus was due either partially or wholly to the intentional, accidental, or negligent acts or omissions of the TEMIMA.

2. I hereby knowingly, voluntarily, affirmatively, fully, and irrevocably waive any and all legal rights to file any claim, action, or lawsuit described in Section 1 above. I hereby so waive such rights on behalf of myself, my spouse or partner, Student(s), heirs and assigns, and agents.

3. In the event that a third party, on behalf of itself or me, successfully or unsuccessfully attempts to assert any legal rights waived by me herein, I further hereby agree to indemnify the TEMIMA, its officers, directors, employees, members, and agents against any judgment or verdict against any of them, including all attorney fees and legal costs.

4. This Agreement shall be governed by and construed according to the laws of the State of Georgia, without regard to its conflict of laws principles. I hereby expressly consent to the personal jurisdiction of the state and federal courts for Georgia in any lawsuit filed there against me by TEMIMA arising from or related to this Agreement.

Permission for Off-Site Field Trips

Indemnification and Release of Liability

This indemnification and release of liability is given by the undersigned legal parent/guardian in favor of TEMIMA.

In consideration of permitting the Student to engage and attend in various field trips off of TEMIMA’s premises (“Field Trip”), the parent/guardian:

1. Agrees that prior to the Student engaging in and attending any Field Trip, the PARENT/GUARDIAN shall conduct its own independent inquiry as to the nature of the Field Trip and any safety measures established for such Field Trip. If PARENT/GUARDIAN believes anything is unsafe, it shall immediately advise TEMIMA of such condition(s) and refuse to engage in any such Field Trip.

2. Acknowledges and fully understands that the Student will be engaging in activities that may involve risk of serious injury, including permanent disability and death, and damage to property which might result not only from its and their actions, inactions, or negligence, but the actions, inactions, and negligence of others, the rule of play, or the condition of a particular Field Trip transportation or location, or of any equipment used. Further, that there may be other risks not known or not reasonably foreseeable at this time.

3. Agrees to indemnify, forever defend, save, and hold TEMIMA, its officers, directors, trustees, employees, members, and agents harmless from and against any and all liability or loss, including attorney’s fees, due to death or personal injury to any person, or from damage to the property of either TEMIMA or any other person, association, or corporation, arising from or out of the Student’s engaging in the Field Trip, with the exception of any such death, injury, or damages caused by the intentional or negligent acts of TEMIMA, its officers, directors, trustees, employees, members, and agents, regardless of fault.

4. Agrees that none of TEMIMA, its officers, directors, trustees, employees, members, and agents shall be liable to PARENT/GUARDIAN or the Student in damages or otherwise for injury loss suffered by any person arising from any defect in the construction, maintenance, or operation of the premises, or any equipment therein, and PARENT/GUARDIAN hereby releases, covenants not to sue, indemnifies, and agrees to hold harmless the TEMIMA, its officers, directors, trustees, employees, members, and agents thereto.

This Indemnification and Release of Liability is effective beginning August 24, 2022 and shall automatically terminate on June 16, 2023, unless otherwise revoked or terminated earlier thereto.

Permission for Student to Leave Campus

1. The undersigned Parent/Guardian hereby consents to allow TEMIMA to permit the above named Student to leave TEMIMA premises (the “Premises”) at certain times, including, but not limited to, lunch, free period, or for any scheduled appointment.

2. This Consent Form is effective beginning August 24, 2022, and shall automatically terminate on June 16, 2023, unless otherwise revoked or terminated earlier thereto.

3. The Parent/Guardian acknowledges that TEMIMA will not be monitoring or otherwise supervising the Student at any time after the Student leaves the Premises. The Parent/Guardian acknowledges that they are responsible, and TEMIMA is specifically not responsible, for the Student’s safety during that time, and the Parent/Guardian assumes all responsibility and liability for the Student.

4. The Parent/Guardian agrees to indemnify, forever defend, save, and hold TEMIMA, its officers, directors, trustees, employees, members, and agents harmless from and against any and all liability or loss, including attorney’s fees, due to death or personal injury to any person, or from damage to the property of either TEMIMA or any other person, association, or corporation, arising from or out of the Student having left the premises.

5. The Parent/Guardian acknowledges that if the Student fails to return timely to TEMIMA, the Student may be disciplined and/or punished in accordance with TEMIMA’s policies and procedures, and shall forfeit all future off-campus privileges.

6. The Parent/Guardian acknowledges that he/she is the residential Parent/Guardian of the Student, and has the legal authority to provide the consent contained herein and to execute this Consent Form.

7. Notwithstanding anything to the contrary contained herein, TEMIMA reserves the right, at any time and for any reason, to refuse to allow or permit the Student from leaving the Premises.

Release of Liability

In consideration of TEMIMA, its officers, directors, trustees, employees, members, volunteers, and agents arranging for the attendance of my daughter at TEMIMA for the current academic year, and in consideration of TEMIMA’s providing the opportunity for and permitting my daughter to attend, participate, and/or take part in the programs of TEMIMA, including, but not limited to, academic, religious, athletic, and social, I (we) do hereby release, remise, and forever discharge, indemnify, and agree to hold harmless TEMIMA, its officers, directors, trustees, employees, members, volunteers, and agents, and/or any one or more of any thereof against any claim, demand, or cause of action, whether now in existence, or hereafter arising out of, resulting from, caused by, occurring during, or in any way connected with the aforesaid attendance at TEMIMA, whether or not such injury, death, or damage is caused by or contributed to in whole or in part by any action or failure to act, negligence, breach of contract, or other misconduct on the part of the TEMIMA, its officers, directors, trustees, employees, members, volunteers, and agents, any other participant in said TEMIMA and/or as any participating parent and/or any one or more of any thereof excluding any willful misconduct or gross negligence. For purposes of allowing TEMIMA students to review classes that they may have missed, TEMIMA may be recording all remote and live classes given. Each parent and child by receipt of this document, and by virtue of their enrolling their daughter or daughters at TEMIMA, agrees to all of the terms and conditions of this Indemnification and Release of Liability.

Confirmation

By affixing my signature below, I hereby acknowledge that I accept all of the terms and conditions of each and every one of the forms above, specifically including the Medical Release, COVID 19 Waiver and Indemnification, Permission for Student to Leave Campus, Release of Liability, and Permission for Off-Site Field Trips.

I confirm that I have read and have agreed to abide by the student handbook and the COVID-19 Addendum.

I also acknowledge that by affixing my signature below, I am delivering an electronic signature that will have the same effect as an original signature on paper or other hard-copy. The electronic signature is equally as binding, and shall have the full force and effect, as an signature on paper or other hard-copy.

Name of Parent Signing Below *

First Name Last Name

Date *

Month Day Year

Signature (Click and drag) *

Clear