Language
English (US)
Armenian
Karapetyan Elementary School
Registration and Medical Form
Student Information
Student's Name
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First Name
Last Name
Date of Birth
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Day
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Month
Year
Date Picker Icon
Year Group
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Please Select
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Parent/Guardians Name
First Name
Last Name
Emergency Contact Details
Contact Person
*
First Name
Last Name
Relationship to child
*
Home phone
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Mobile phone
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Email or other
Please list anyone that is allowed to pick up your child from school.
Medical Details
Health Insurance Provider
*
Address of Provider
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Policy number or plan
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Family Doctor
Doctor's Name
*
First Name
Last Name
Address
*
Contact number
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Pre-existing medical, social or emotional conditions you would like us to be aware of?
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Yes
No
Details
Regular medication?
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Yes
No
Details
Allergy sufferer?
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Yes
No
Details
I/we give permission for our child to be given medication for minor conditions such as headaches (Dafalgan or Dafalgan Syrup, Panadol) sore throats (Mebucaine, Neo-Angin), travel sickness (Dramamine) etc should my child request it.
Yes
No
List here any exceptions i.e. medication that you know your child is allergic to or is otherwise
Special Dietary Requirements
Does your child have any special dietary requirements? e.g. vegetarian
Yes
No
General Declaration
Details
The Parent listed as the Parent or Guardian above should complete the boxes on the right and sign below.
I hereby give permission to this academy staff and their agents to authorize on my behalf any emergency medical care (including surgery) which, on the recommendation of qualified medical personnel, may be deemed necessary. In such circumstances, I understand this Academy staff or their agents will seek to advise me at the earliest possible convenience.
*
Yes
No
In signing this form, I give permission for my son/daughter to participate in all activities relating to the school program (including at clubs, field trips and ski trips, details of which may be forwarded to me at a later date). I will attach any exceptions in writing on a separate piece of paper here and I acknowledge that exemption may only be possible with proof of a medical certificate.
*
Yes
No
I authorize that my child may have periods of unsupervised free time during off-site trips, as deemed reasonable and appropriate by this Academys staff. Details of these may be forwarded to me by trip organisers on my request.
*
Yes
No
Acknowledgment
To the best of my knowledge, the information I have given above is correct. I will make every attempt to keep the office updated of any changes to this form throughout the school year. I release this School and it’s instructors, independent contractors, and all other associates from liability for harm, theft, or injury that may be suffered by me and/or members of my family traveling to or from or during participation in activities and programs sponsored by Academy. I hereby acknowledge that I am voluntarily assuming full responsibility for all risks of physical injury arising out of active participation in class or other related activities. I acknowledge the contagious nature of COVID-19 and other contagious diseases and viruses and voluntary assume the risk that I and/or my children may be exposed to or infected by COVID-19 by attending and participating and that such exposure or infection may result in personal injury ,illness, permanent disability, and death. I understand and agree that they do not require vaccines or immunizations for enrollment. I understand that the risk of becoming exposed to or infected by COVID-19 and other contagious diseases and viruses may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, independent contractors, volunteers, and program participants and their families. I release this Academy, its instructors, independent contractors and all associates from liability for harm, injury or death pertaining to COVID-19 and other contagious diseases and viruses. I understand that there are NO refunds for registration fees, costume, performance fees or classes. I understand that if class gets cancelled due to weather, sickness, or any issues arising from COVID-19 or any other infections, diseases, or sickness there is no refund for these missed classes. I understand and agree to this Schools policies and procedures. I understand that my student must have this release form signed before attending class. I understand and give permission to assist myself or my child to the restroom including changing diapers, or any accidents student might have. I give permission to this School to use pictures and or video of my child for advertising purposes in print, promotional videos and on the website. Both parent and/or student understand that we must be notified at least 30 days prior to student disenrollment from any program. I understand that we do not require its employees, affiliates, students, instructors, or independent contractors to get vaccinated, or wear a mask throughout their time at the Academy.
The parent acknowledges that they must give at least 30 days notice prior to students dis-enrollment. There will be no discounts on the fees if child is absent unless authorized by Head of School. If no notice given, I understand that I forfeit any payment made for current month and can be charged an additional fee.
I Understand
The parent acknowledges and agrees that tuition is due by the 1st of each month. If payment is not received by this date, a late fee of 10% of the outstanding amount will be applied.
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I Understand
The parent acknowledges and agrees that a fee of $25 will be charged for every 5 minutes they are late in picking up their child
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I Understand
Signature of Parent or Guardian
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First Name
Last Name
Date
*
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Day
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Month
Year
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Submit
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