The Franklin Academy / 2021-22 Annual Student Info Form

2021-2022 Annual Student Info Update

Step 1: Complete this online form.
General Student Information
Student Name

First NameLast Name
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade Level in Fall 2021
Contact Information
Parent/Guardian 1

First NameLast Name
Relationship to Student
Parent/Guardian 1 Email Address
example@example.com
Parent/Guardian 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Place of Employment
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2

First NameLast Name
Relationship to Student
Parent/Guardian 2 Email Address
example@example.com
Parent/Guardian 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Work Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Student Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize the below Emergency Contact(s) to pickup my student from school.
Emergency Contact 1

First NameLast Name
Relationship to Student
Emergency Contact 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2

First NameLast Name
Relationship to Student
Emergency Contact 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
OFF-CAMPUS ACTIVITIES: The student has permission to travel with The Franklin Academy, within Whatcom County, under the direction of chaperones, for school sponsored off-campus activities. Protocol requires parent drivers to have their driving record and insurance documentation on file at The Franklin Academy.
MEDIA PERMISSION: Photography and /or other likeness (such as video or voice recording) The Franklin Academy may photograph or otherwise capture the student's likeness and use the image or recording in print and/or online materials for any lawful purpose related to the business of the school. The student may or may not be identified by name. In granting permission, the parent waives the right to review and approve the use of the student's likeness prior to publication/dissemination. The Franklin Academy has permission to use the likeness of my student, in the manner as described above.
Student Medical Information

We require an updated Annual Health History each school year, the information provided will be shared with pertinent staff members to ensure your students safety at school.
Primary Care Provider Name

First NameLast Name
Primary Care Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dentist Name

First NameLast Name
Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Dental Exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
COVID-19 Vaccine. If fully vaccinated, date of 2nd dose.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Health Concerns
Life-Threatening Conditions

If your child has a serious health condition, it is vital that you discuss this with your school nurse immediately. Washington state law (RCW 28A.210.320) requires that medication or treatment orders, medications, and a health care plan be in place PRIOR to the start of the school. Your school nurse will work with you to develop a plan for your child. Please contact the nurse through the school office.
Please check the appropriate box and the questions after it.
Asthma - Does your child require a rescue inhaler while at school?
Allergy - List allergen(s)
Diabetes Diagnosis Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Diabetes Type
Diabetes - Form of Medication
Seizure - Type
Date of Last Seizure

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do your child's seizures require medication?
Any NON life-threatening health conditions or concerns that could affect your child at school
Medications

Includes prescription, supplements, and over-the-counter medications
My Student Requires Medication(s) at School
1. A doctor and parent signed Athorization to Adminster Medication at School form must be on file, before any medications will be administered at school.
2. All medications must be in the original container with a pharmacy label that matches the health care provider's order.
Emergency Preparedness - Medical/Dietary Conditions: We request that parents/guardians of students with serious medical/dietary conditions provide medication and/or appropriate food to be kept at school in case there is an emergency that would detain them at school. A three-day supply is requested.
Emergency Medical Release & Immunization Information Recording

In the event of any emergency, if the school is unable to contact a parent or guardian, The Franklin Academy is authorized to contact 911, a licensed ambulance service, or to transport the child to an appropriate medical facility. Any expenses will solely be the obligation of the parent/guardian. I give permission to my child's school to add immunization information with the Washington Immunization Information System (WAIIS) to help the school maintain my child's school record.
Parent/Guardian Initial
Parent Handbook

I confirm that I have read, understand and agree to The Franklin Academy's policies outlined in the Parent Handbook.
Parent/Guardian Signing Form

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Should be Empty:

2021-2022 Annual Student Info Update

General Student Information

Contact Information

Student Medical Information

Life-Threatening Conditions

Medications

Emergency Medical Release & Immunization Information Recording

Parent Handbook