2024 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 Name:*
Last Name:*
Cell Phone*
Email*
example@example.com
Home Phone*
ADDRESS: WHERE STUDENT WILL BE PICKED UP AND DROPPED OFF DAILY
*We are unable to bus kids to Ferndale, Nooksack, and beyond the reservation borders.
Street*
Apt. #
City/State*
Zip Code*
EMERGENCY CONTACTS
First*
Last name*
Home Phone
Cell Phone*
First*
Last name*
Home Phone
Cell Phone*
AUTHORIZATIONS

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*

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 #
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
HEALTH/MEDICAL INFORMATION
Student Name:*
Physician Name: *
Physician Phone: *
HEALTH CONDITIONS/MEDICAL DIAGNOSES
MEDICATIONS
MEDICATON:
REASON FOR MEDICATION:
MEDICATION DOSE:
DIRECTION FOR MEDICATION:
MEDICATION TAKEN ONSITE (IF YES, YOU MUST SEE THE LNS NURSE FOR A FORM TO TAKE TO YOUR PHYSICIAN):

YESNO
MY CHILD HAS A LIFE THREATENING CONDITION (PLEASE NOTIFY THE NURSE):

YESNO
ALLERGY INFORMATION
STUDENT ALLERGY:

NONEFOODMEDICATIONENVIRONMENTAL
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 the After-School 21st Century Program. By signing below, you hereby request that your student, be allowed to keep the appropriate prescribed device on his/her person or with the nurse, while participating in the After-School 21st Century Program.
STUDENT NAME:
Signature

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

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS

AUTHORIZATIONS

AUTHORIZATION FOR PICK UP

PHOTOGRAPHY RELEASE

CODE OF CONDUCT/RULES/EXPECTATIONS

PARENT AUTHORIZATION

HEALTH/MEDICAL INFORMATION

MEDICATIONS

ALLERGY INFORMATION

WAIVER TO CARRY EMERGENCY MEDICAL DEVICE

AUTHORIZATION FOR EMERGENCY PROCEDURE