Student Information and Emergency Form

Student Information and Emergency Form
Child's Name*

First NameLast Name
Nickname- write "none" if n/a*
Gender*
Race*
As a non-profit organization, Kinhaven is required to report this annually.
Birthdate*

MonthDayYear
Date
Child's Home Address*

Street Address

Street Address Line 2

CityStateState / Province

Zip
Home Phone Number*
Please enter a valid phone number.
This child's birth certificate lists:

1 Parent2 Parents
Parent 1 Full Name*

First NameLast Name
Home Address if different than above
include street, city, state, and zip code
Home Phone Number if different than above
Please enter a valid phone number.
Parent 1 Mobile Phone Number*
Please enter a valid phone number.
Parent 1 Business Phone Number*
Please enter a valid phone number.
Parent 1 Email*
example@example.com
Name of Employer*
Enter "none" if parent is not employed.
Employer Address*
Include street, city, state, and zip code. If not employed enter "none."
Parent 2 Full Name*

First NameLast Name
Parent 2 Home Address if different than above
Parent 2 Home Phone Number if different than above
Please enter a valid phone number.
Parent 2 Mobile Phone Number*
Please enter a valid phone number.
Parent 2 Business Phone Number*
Please enter a valid phone number.
Parent 2 Email*
example@example.com
Name of Employer*
Enter "none" if parent is not employed.
Employer Address*
Include street, city, state, and zip code. If not employed enter "none."
In the following section, list two (2) Emergency Contacts to be used if parents cannot be reached. Each contact must reside in the DC Metro Area.
Emergency Contact 1
Full Name*
Relationship*
Address*

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Daytime Phone Number*
Please enter a valid phone number.
Emergency Contact 2
Full Name*
Relationship*
Address*

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Daytime Phone Number*
Please enter a valid phone number.
Name of any individual(s) responsible for bringing or picking up your child on a regular basis*
Additional Persons Authorized to Pick Up Your Child
Person(s) Not Authorized to pick up: Child Appropriate paperwork such as a divorce decree shall be attached if a parent is not allowed to pick up a child.
Name of Child's Physician*
Phone Number*
Health Insurance Carrier*
Name of Insured*
Policy ID Number*
Known Medical Problems/Allergies (attach a separate sheet if needed)*
Medication will need to be administered by the school*

NoYes- Please provide additional documentation to the school
Acknowledgements
I have received or have access to the internet and can acquire Kinhaven School's Parent Handbook, and will abide by the policies contained therein.*

YesNo (if No, a paper copy will be distributed)
I shall notify Kinhaven School of my child's absences due to illness and report symptoms. I shall also notify Kinhaven School if a member of my child's household contracts a reportable communicable disease. Kinhaven School will notify me via established communication channels if a classmate of my child contracts a reportable communicable disease. (see Health and Safety: Exclusion of a Sick Child and Report a Sick Child for more information)*

YesNo
I hereby give permission without restriction to Kinhaven School and its assignees to photograph or video record my child while at school or during participation in school-sponsored activities. I specifically waive any rights to compensation with respect to my child's name, likeness, picture, and/or voice. The purpose of this release is to facilitate education and communication between home and school, support ongoing development and training, and for occasional use in promotional materials.*

YesNo
Field Trip/Walk-About Permission
My child has my permission to take Walk-Abouts (neighborhood walks, park visits, ) with his/her class.*

YesNo
My child has permission to go on all Field Trips with his/her class. I understand that Kinhaven School will inform me at least one week prior to each field trip.*

YesNo
Use of Provided Information
I understand that the information provided will be used to contact me in case of emergency and may be used by an outside emergency call center.*

YesNo
I will provide Kinhaven School with any changes in student or contact information within 5 business days of such change.*

YesNo
The parent/guardian contact information listed above may be included in the Kinhaven School Directory that will be distributed to all families.*

YesNo
I agree to use the Kinhaven School directory and the information contained therein for family or school business only. I shall not use the information to solicit on behalf of other business, charitable, or political organizations.*

YesNo
Emergency Permissions
My child may be treated for minor scrapes and cuts with:
First Aid Cream*

YesNo
Antibiotic Ointment*

YesNo
Sunscreen*

Kinhaven may apply school supplied sunscreen (mineral sunscreen, minimum 50SPF)I will supply my sunscreen for my child for Kinhaven staff to applyI do not consent to sunscreen application while my child attends Kinhaven School
Should my child become ill during school hours, I understand and agree that it is my responsibility to pick up my child immediately upon notification from the school.*

YesNo
If the school is unable to contact anyone listed on this card or in the event of a life threatening emergency, I give Kinhaven School permission to use the Rescue Squad to transport my child to the hospital, if necessary and give hospital personnel the permission to treat my child.*

YesNo
In the event of an emergency involving the school building, I understand that my child may be relocated to the Arlington County Central Library at 1015 N. Quincy Street.*

YesNo
I understand that should I be called by the Emergency Call Center and asked to pick up my child, I will proceed to the designated pickup location immediately.*

YesNo
If you have answered No to any of the above questions, please address your desires separately in writing here.
Signature of Parent or Guardian*

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Student Information and Emergency Form

Emergency Contact 1

Emergency Contact 2

Acknowledgements

Field Trip/Walk-About Permission

Use of Provided Information

Emergency Permissions