Summer Application 24

STUDENT INFORMATION

(Please use N/A for any fields that may not apply to you)
Todays date

MonthDayYear
Date
Current School*
Current Grade 2023/2024*
First*
Last Name:*
Middle*
Age*
Birthdate MM/DD/YYYY*
Gender M/F*

MaleFemale
PARENT/GUARDIAN INFORMATION
1. First Name:*
Last Name*
Email*
example@example.com
Cell Phone*
Home Phone:
2. First Name:*
Last Name:*
Email:*
Cell Phone: *
Home Phone:
ADDRESS: WHERE STUDENT WILL BE PICKED UP AND DROPPED OFF DAILY
Street:*
Apt. #:
City/State:*
Zip:*
Emergency Contacts
1. First Name:*
Last Name:*
Cell Phone:*
Home Phone:*
2. First Name:*
Last Name:*
Cell Phone: *
Home Phone: *
Insurance Information
Primary Insurance*
Subscriber Name*
Group#*
Policy#*
Secondary Insurance
Subscriber Name
Group#
Policy#
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize LNS 21st Century Summer School or insurance company to release any information required to process my claims.
SCHOOL HEALTH/MEDICATION FORM
Student Name*
Physician Name*
Physician Address*
Medication*
Reason for medication*
Medication dose*
Direction for medication*
Medication taken on site:*

YesNo
*If yes, you must see the LNS school nurse for a form to take to your physician.
Directions*
My child has a life threatening condition – please notify the nurse:*

YesNo
ALLERGY INFORMATION
Student Allergy:*

NoneFoodMedicationEnvironmentalOther
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, *SIGN BELOW, hereby request that *STUDENT NAME BELOW be allowed to keep the appropriate prescribed device on his/her person or with the nurse, while participating in summer school.
Clear
Student Name:*
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 be transported by Lummi Nation School, J.O.M., Youth Outreach, or LTHC employees as deemed necessary for school or emergency related purposes. I understand that students are expected to remain with the group unless written permission is given by me to do otherwise.
Check Box:*

YesNo
AUTHORIZATION FOR PICK UP
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.*

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.*

YesNo
Code of Conduct/Rules/Expectations

YesNo
I have read, understand, and have reviewed with my child the Lummi Nation School Policies and Procedures found at: https://www.lns-onlinelearning.org/_files/ugd/cb3d79_ea88c78726704cceba7ad8bc6353b492.pdf I acknowledge that my child/children will be subject to all Lummi Nation School’s Policies and Procedures while attending the summer school program.
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 School2334 Lummi View DriveBellingham, WA 98226
Should be Empty:

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

ADDRESS: WHERE STUDENT WILL BE PICKED UP AND DROPPED OFF DAILY

Emergency Contacts

Insurance Information

SCHOOL HEALTH/MEDICATION FORM

*If yes, you must see the LNS school nurse for a form to take to your physician.

ALLERGY INFORMATION

WAIVER TO CARRY EMERGENCY MEDICAL DEVICE

AUTHORIZATION FOR EMERGENCY PROCEDURE

AUTHORIZATIONS

FIELD TRIPS/STUDENT TRAVEL

AUTHORIZATION FOR PICK UP

SUNSCREEN

Photography Release

PARENT AUTHORIZATION