LNS After School Program Application

STUDENT INFORMATION

2024-2025
Today's date

MonthDayYear
Date
Current School*
Current Grade: *
First*
Last name*
Middle*
Age*
Birth date:*
Gender*

MaleFemale
SPED (Check Box)*

YesNo
PARENT/GUARDIAN INFORMATION
First*
Last name*
Cell Phone*
Email*
example@example.com
Home Phone*
First*
Last name*
Cell Phone*
Email*
example@example.com
Home Phone*
ADDRESS: WHERE STUDENT WILL BE PICKED UP AND DROPPED OFF DAILY
Street*
Apt. #
City/State*
Zip Code*
EMERGENCY CONTACTS
First*
Last name*
Home Phone
Cell Phone*
First*
Last name*
Home Phone
Cell Phone*
INSURANCE INFORMATION
Primary Insurance
Subscriber Name
Group #
Policy #
Secondary Insurance
Subscriber Name
Group #
Policy #
SCHOOL HEALTH/MEDICATION FORM
Student Name*
Physician Name*
Physician Address*
MEDICATIONS
Medication
Reason for medication
Medication dose
Direction for medication
Medication taken on site:

YesNo
Directions for nurse:
My child has a life threatening condition - please notify the nurse:*

YesNo
ALLERGY INFORMATION
Student Allergy

None
Food
Medication
Environmental
Describe allergy
Required treatment
Does student carry a medical device?*

YesNo
WAIVER TO CARRY EMERGENCY MEDICAL DEVICE
The prescribed device is:

InhalerEpi PenOther
All emergency medical devices (inhalers, EpiPens, etc. must be carried on the individual's person or with the nurse, while attending summer school, I, as the legal guardian/parent hereby request that my child be allowed to keep the appropriate prescribed device on his/her person or with the nurse, while participating in summer school
Signature*

Clear
Child's Name:*
OTHER HEALTH CONCERNS
Please describe any other health concerns
AUTHORIZATION FOR EMERGENCY PROCEDURE
I hereby represent that the above information is correct. I am authorized to provide the medical information and release authorization contained herein and agree to release Lummi Nation School and its agents from any and all liability arising as a result of this waiver. If the parents and authorized physician named on the registration record cannot be reached at the time of an emergency and the immediate observation or treatment is urgent in the judgment of the school authorities, I authorize and direct the school authorities to send the accompanied child to the hospital or doctor most easily accessible. I understand that I will assume full responsibility for the payment of any services rendered.
Signature*

Clear
Date

MonthDayYear
Date
AUTHORIZATIONS

FIELD TRIPS/STUDENT TRAVEL
I give permission for my child to participate in classroom/school field trips. I also give permission for my child to betransported by Lummi Nation School, J.O.M., Youth Outreach, or LTHC employees as deemed necessary for school oremergency related purposes. I understand that students are expected to remain with the group unless writtenpermission is given by me to do otherwise.*

YesNo
AUTHORIZATION FOR PICK UP
The following people are authorized to pick up my child/children:
Name*
Cell phone #*
Name
Cell phone #
Name
Cell phone #
Name
Cell phone #
SUNSCREEN

I understand that I am responsible for supplying sunscreen to my child to be used while at summer school
CHECK BOX:*

YesNo
PHOTOGRAPHY RELEASE

I give permission to use and reproduce my child’s name/image for promotional purposes related to Lummi Nation School and the 21st Century grant.
CHECK BOX:*

YesNo
CODE OF CONDUCT/RULES/EXPECTATIONS

I have read, understand, and have reviewed with my child the Lummi Nation School Policies and Procedures found at: https://www.lns-onlinelearning.org/ - I acknowledge that my child/children will be subject to all Lummi Nation School’s Policies and Procedures while attending the summer school program.
CHECK BOX:*

YesNo
PARENT AUTHORIZATION

I authorize that I understand and have given consent to the above waivers, releases, and permissions.
Signature*

Clear
Date

MonthDayYear
Date
Lummi Nation School 2334 Lummi View Drive Belingham, WA 98226
Should be Empty:

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS

INSURANCE INFORMATION

SCHOOL HEALTH/MEDICATION FORM

MEDICATIONS

ALLERGY INFORMATION

WAIVER TO CARRY EMERGENCY MEDICAL DEVICE

OTHER HEALTH CONCERNS

AUTHORIZATION FOR EMERGENCY PROCEDURE

AUTHORIZATIONS

SUNSCREEN

PHOTOGRAPHY RELEASE

CODE OF CONDUCT/RULES/EXPECTATIONS

PARENT AUTHORIZATION