Orchard Park Academy Akron

Emergency Medical Authorization
Student's Name*

First NameLast Name
Age
Address*

Street Address

Street Address Line 2

State / Province
City*
Zip*
State*
Student Phone Number*
Emergency Medical Authorized?*
Purpose - To enable parents and guardians to authorize the provision of emergency treatment for their student who becomes ill or injured while under the school's authority when parents or guardian cannot be reached.
Residential Parent or Guardian
Parent/ Guardian 1: Name

First NameLast Name
Parent/ Guardian 1: Phone Number
Parent/ Guardian 2: Name

First NameLast Name
Parent/ Guardian 2: Phone Number
Other: Name

First NameLast Name
Other: Phone Number
Part 1 - Grant Permission

I hereby give my consent for the following medical care providers and local hospital to be called:
Doctor's Name:
Doctor's Phone:
Dentist's Name:
Dentist's Phone:
Medical Specialist Name:
Medical Specialist's Phone:
Local Hospital Name:
Local Hospital Phone:
In the event reasonable attempts to contact me have been unsuccessful I hereby give my consent for (1) the admission of any treatment deemed necessary by above named doctor; or the event the designated preferred practitioner is not available, by another licensed physician or dentist and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery sunless the medical options of two other licensed physicians or dentists concur in the necessity for such surgery are obtained prior to the performance of such surgery.

Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:
Additional Medical Information
Part 2 - Refusal to Consent

I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the School authorities to take the following actions:
Alternative Instructions
This Emergency Information and Immunization Record Card is accurate and complete and was provided by:
Parent/ Guardian/ Student 18 and older: *

First NameLast Name
Parent/ Guardian / Student 18 and older: Signature*

Clear
Date

MonthDayYear
Date

Student Release Form

I agree my student may be physically released only to the following person(s). These person(s) may also be called in the event of an emergency. Proof of identification, in the form of picture ID is required when picking up child(ren). Changes of any release / contact selections must be received in written form.
Release 1: Name*
Release 1: Phone Number*
Release 1: Relationship to Student*
Release 1: Type of Authorization Granted*
Release 2: Name*
Release 2: Phone Number*
Release 2: Relationship to Student*
Release 2: Type of Authorization Granted*
Release 3: Name
Release 3: Phone Number
Release 3: Relationship to Student
Release 3: Type of Authorization Granted
Release 4: Name
Release 4: Phone Number
Release 4: Relationship to Student
Release 4: Type of Authorization Granted

Appendix A: Language Usage Survey
Parents and Guardians: A completed language usage survey is required for all students open enrollment in Ohio schools. The information will tell school staff if they need to check the student's proficiency in English. Answers to these questions ensure the student receives the education services to succeed in school. The information is not used to identify immigration status.
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Communication Preferences

Indicate your language preference so we can provide an interpreter or translated documents at no cost when you need them. All parents have the right to information about the student's education in a language they understand.
Family Preferred Communication Language
Language Background
Information about the student’s language background helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed.
Student's first language?
Student's most used language
What languages are used in your home?
Prior Education
Responses about your student's birth country and previous education give us information about the knowledge and skills the student is bringing to school and may enable the school to receive additional funding to support the student.
In what country was the student born?
Has the student ever received formal education outside of the United States?

YesNo
If yes, how many years/months?
Has the student attended school in the United States?

YesNo
If yes, when did the student first attend a school in the United States?

MonthDayYear
Date
Additional Information: Please share additional information to help us understand the student's language experiences and background.
Language and Education Info
Parent/ Guardian/ Student 18 and older Name: *
Parent / Student 18 and older: Signature*

Clear
Date

MonthDayYear
Date

Media Release
Name of Participating Student*

First NameLast Name
Age
Grade
I/we understand that as part of my/our student's attendance at [INSERT SCHOOL NAME HERE] (“School”), photos, videos, and quotations may be taken for use in publications and reports about the program. I/we further understand that members of the news media invited to cover the program may take photos, videos and quotations.

I/we grant permission to the School and its Board of Directors, Management Company, employees, agents and representatives to use such materials for the promotion of the program and to use this student’s name, photographic likeness, alone or in a group, in any publication, document, TV production, video or to release said name or likeness to any media outlets including, but not limited to, newspapers, magazines or TV stations for publicity and/or recognition purposes and/or to use this student’s name and/or photographic likeness, alone or in a group, on the official website of the School and/or Management Company.

I agree that I and/or my student shall have no right, title, or interests in any photo or videotape covered by this agreement and waive any right to compensation for such use. I release the School, its Board of Directors, the Management Company, employees, agents, representatives and all organizations and individuals related to the School from any and all liabilities or damages that result from the use of this student’s name and/or photographic likeness as described above.
Student Name*

First NameLast Name
Parent/ Guardian Name*
Parent Signature*

Clear
Date

MonthDayYear
Date

Activity Authorization Form
I hereby authorize the release and disclosure of the personal health information of this ("Student"), as described below, to the ("School"). The information described below may be released to the School principal or assistant principal, coach, physical education teacher, school nurse or other member of the School's administrative staff as necessary to evaluate the Student's eligibility to participate in school sponsored activities, including but not limited to interscholastic sports programs, physical education classes or other classroom activities.

Personal health information of the Student which may be released and disclosed includes records of physical examinations performed to determine the Student's eligibility to participate in school sponsored activities, including but not limited to the Pre-participation Evaluation form or other similar document required by the School prior to determining eligibility of the Student to participate in classroom or other School sponsored activities; records of the evaluation, diagnosis and treatment of injuries which the Student incurred while engaging in school sponsored activities, including but not limited to practice sessions, training and competition; and other records as necessary to determine the Student's physical fitness to participate in school sponsored activities.

The personal health information described above may be released or disclosed to the School by the Student's personal physician or physicians; a physician or other health care professional retained by the School to perform physical examinations to determine the Student's eligibility to participate in certain school sponsored activities or to provide treatment to students injured while participating in such activities, whether or not such physicians or other health care professionals are paid for their services or volunteer their time to the School; or any other EMT, hospital, physician or other health care professional who evaluates, diagnoses or treats an injury or other condition incurred by the student while participating in school sponsored activities.

I understand that the School has requested this authorization to release or disclose the personal health information described above to make certain decisions about the Student's health and ability to participate in certain school sponsored and classroom activities, and that the School is a not a health care provider or health plan covered by federal HIPAA privacy regulations, and the information described below may be re-disclosed and may not continue to be protected by the federal HIPAA privacy regulations. I also understand that the School is covered under the federal regulations that govern the privacy of educational records, and that the personal health information disclosed under this authorization may be protected by those regulations.

In understand by its nature, participation in interscholastic athletics includes risk of injury and transmission of infectious disease such as HIV and Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning program, and inspect their own equipment daily.

I understand that in the case of injury or illness requiring transportation to a health care facility that a reasonable attempt will be made to contact the parent or guardian in the case of the student-athlete being a minor, but that, if necessary, the student-athlete will be transported via ambulance to the nearest hospital.

I also understand that health care providers and health plans may not condition the provision of treatment or payment on the signing of this authorization; however, the Student's participation in certain school sponsored activities may be conditioned on the signing of this authorization.

I consent to the use of the herein named student's name, likeness, and athletic-related information in reports of contests, promotional literature and other materials and releases related to interscholastic athletics.
This authorization will expire at the conclusion of the present school year.
Student Name*

First NameLast Name
Parent/ Guardian Name*

First NameLast Name
Parent/ Guardian Signature*

Clear
Date

MonthDayYear
Date

Additional Documentation

These additional documents will be required to complete registration and can be uploaded below or turned in to the School.
Birth Certificate

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Social Security Card

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Proof of Residency

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Can include monthly utility bill, signed lease/rental agreement, monthly mortgage statement, rent receipt, paycheck with address on it or monthly bank statement. Cancelof
Immunization Records

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Parent/Guardian ID

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ONLY from address at which the student is living Cancelof
School Transcripts

Browse Files

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If applicable, please upload a copy of the student's I.E.P. and Evaluation.

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If applicable, please upload a copy of the student's 504 Plan.

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Should be Empty:

Student Information

Parent / Guardian Information

Student's Family Data

Emergency Medical Authorization

Student Release Form

Appendix A: Language Usage Survey

Media Release

Activity Authorization Form

Request for Records

Additional Documentation