Health and Safety Waiver
School Year 2026-2027
Primary Family Email
*
example@example.com
VERY IMPORTANT: Please list all of your student(s) who will be enrolled in Harbor:
*
Rows
Student First Name
Student Last Name
Food Allergies*
Medical Conditions*
EpiPen*
1
2
3
4
5
6
7
Parent/Guardian:
*
Rows
Parent Name: First/Last
Mobile phone:
Other phone:
Email:
1
2
Primary Address:
*
Street Address
(optional) Street Address Line 2
City
State / Province
Postal / Zip Code
If parents cannot be reached:
*
Rows
Parent Name: First/Last
Mobile phone:
Relation to student
1
Medical Waiver and Release:
*
Medical Care Authorization: In case of an emergency, I authorize the Harbor Homeschool team to take such measures and arrange for such medical and hospital treatment as they may deem advisable for my child’s health and wellbeing. I release Harbor Homeschool, the staff, volunteers, and the Dearborn Free Methodist Church from claim or liability due to sickness or injury. I accept all financial responsibilities concerning any medical emergency that arises.
Liability: In consideration for my child’s participation in activities sponsored by Harbor Homeschool, I hereby release, discharge, indemnify, and agree to hold harmless Harbor Homeschool, its directors, officers, and employees, agents, all volunteer personnel, and the Dearborn Free Methodist Church from any and all liability for personal injuries, damage(s) and/or illness that may be suffered. I further agree to indemnify and hold harmless Harbor Homeschool, its directors, officers, employees, agents, and all volunteer personnel concerning any awarded claim and/or damages as a result of any injury or damage. This includes reasonable attorney fees, litigation expenses, and court costs.
Publication Release: As part of classroom/school projects, or the Harbor Homeschool Yearbook, the school occasionally uses photos or video of students. As a parent and/or guardian for the named child(ren), I give my permission for the use of photos or videos that contain my child and will hold Harbor Homeschool and its board and employees harmless from any liabilities in connection to printed or online publications.
Medical Action Plan Forms (MAP)
*
I understand that if my child has a medical condition, allergy or medication (as listed above), I am required to fill out one of the Medication and Medical Action Plan Forms (MAP) and submit it with your OVA paperwork AND return forms to Jenny Matteson at jenny.matteson@oxfordschools.org AND Sarah Andrews at s.andrewshha@gmail.com
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: