Mandatory Information Forms Packet for Grade 6 This packet contains the remaining forms required for the 2013-2014 school year. These forms must be printed, completed, and returned to Trinity Prep by Friday, May 24, 2013. STUDENT COURSE SCHEDULES WILL NOT BE RELEASED UNTIL ALL ONLINE INFORMATION AND PRINTED/SIGNED FORMS HAVE BEEN UPDATED AND SUBMITTED. Forms to be printed, completed, and returned include: 1. Emergency Medical Release 2. Field trip forms for grade 6 Please be sure to complete all pages of multi-page forms. ALL NEW STUDENTS must also provide the following by Friday, May 24, 2013: Birth Certificate An original or certified copy of their birth certificate to be copied for our records. We must see the original document. A current passport is acceptable for non-u.s. citizens only. If you cannot file your child s birth certificate, you will need to order one right away as students may not start school without one. Physical exam this form is available only at your pediatrician s office or health clinic. (The FHSAA medical form for students playing sports is also acceptable.) The form must be from a Florida physician and the physical exam must be within one year of school entry unless playing a sport. FHSAA sports physicals must be completed AFTER May 22. If your insurance dictates when your child can receive his/her physical, and it is after the May 24 deadline to complete this process, just call our office with the date you have scheduled your child s physical and his/her schedule will not be held. Immunization valid original FLORIDA DH 680 Immunization Form with required immunizations form or printout available only at your physician s office. a. Hepatitis B series. (If this three immunization series is incomplete, the temporary medical exemption portion of the DH680 form must be completed by the physician.) b. Measles, Mumps, Rubella (MMR) c. DTP series d. Polio series (last one must be after student turned 4 years old). e. Varicella If you are unable to provide a birth certificate, physical, or immunization form by May 24 th, please contact the Admission Office. When you call to let us know you will be delayed, please provide the date by which you will complete the process so that it can be noted in your child s record. * NOTE about Athletics: If your child is going to participate in sports at Trinity Prep anytime during the school year, the FHSAA Consent and Release form and the FHSAA Physical Exam form must be on file. Trinity Prep will hold sports physicals in the DAC on May 22 which will fulfill the new student physical requirement as well as the sports physical requirement. Click here for more information about the sports physicals. http://www.trinityprep.org/page.cfm?p=3493 Sports physicals must NOT be completed prior to May 22 for the 2013-2014 school year. For more information, please go to TrinityPrep.org/athletics. Please contact Patty LaPeters if you have any questions. 321-282-2515 or lapetersp@trinityprep.org
Emergency Medical Authorization/Liability Release - 2013-2014 Student Name Entering Grade Last First Middle Home Phone: Street Address: Date of Birth The above named child is presently attending Trinity Preparatory School. He/She has the following physical or medical limitations, including allergies and prohibited medicine: VERIFICATION OF HOSPITALIZATION INSURANCE FOR CHILD: Company: Policy/I.D. I hereby authorize and consent for the officials of Trinity Preparatory School to employ on my behalf a licensed physician for the emergency treatment of my child, in connection with any injury, accident or illness suffered or sustained while involved with a school activity on or off campus or while in transit. Said authorization and consent for emergency treatment includes hospitalization and surgical as recommended by said physician. I understand that every reasonable effort will be made to notify me of said emergency. I do hereby release Trinity Preparatory School of Florida from all and any medical or hospital expense resulting from any type of accident or injury occurring to our child while involved in any school activity on or off campus or while in transit. Parent/Guardian Signature: Date: Daytime Phones (Father): (Mother): Mobile Phone: Other: In the event that Trinity is unable to reach you during an emergency, please provide the names and phone numbers of two adults whom we may contact on your child's behalf. Name: Phone Number: Name: Phone Number:
Parent Authorization for School Activity Agreement and Release Activity: Sixth Grade Field Trip Sponsor: Trinity Prep Sixth Grade Departing: Wednesday, October 16, 2013 at 6:45 a.m. Returning: Friday, October 18, 2013 at 6:00 p.m. Destination: New Ebenezer Retreat Center, Rincon, Georgia, just outside Savannah Transportation will be provided by Trinity Preparatory School. My son/daughter/ward has my permission to be transported by charter bus. My son/daughter/ward has the following special or dietary needs or allergy: Diabetes Vegetarian Wheat allergy Peanut allergy Seafood allergy Other please explain I am the parent or legal guardian of who is a student at Trinity Preparatory School (the School ). I enter into this Agreement and Release knowingly and willingly. I recognize that whenever the term School is used below, it includes the School s employees and agents. I agree to the following: I understand that appropriate insurance policies are recommended for all overnight trips (As a courtesy, the School offers a voluntary student accident insurance policy through Standard Life and Casualty for a small premium). 1. I give permission for my child to participate in the above referenced activity. 2. I release and hold the School harmless from any injury, loss, or damage resulting from my child s participation in the above referenced activity, including any injury, loss, or damage arising from any act or omission of any, hotel, restaurant, or any other person or entity providing goods or services in connection with the activity, except for acts or omissions that are willful or grossly negligent; 3. I agree to indemnify the School for all injury, loss, or damage to the person or property of others caused by my child; 4. I release and hold the School harmless from any liability for reasonable decisions or actions as may be taken to protect the health and safety of my child; 5. If in the event of an accident or emergency and I am unavailable to provide consent, I authorize the School to provide health care services to my child, at my expense, as deemed necessary, and I release and hold the School harmless from all liability resulting from such health care services; Page 1 of 2
Changes in Medical Condition I provided information in August of my son s/daughter s/ward s medical conditions that may be relevant to a physician in the event of an emergency. Below I have listed changes to that information: Changes in Emergency Contact Information I provided emergency contact information in August. Below are changes since that time: I have read the Agreement and Release thoroughly and agree to be bound to the terms and conditions stated herein: Parent/Guardian Signature: Date: As a student of Trinity Preparatory School, I fully understand my responsibility to act in a manner, which represents the School proudly. I understand that my parents or guardian may be notified and I may be sent home if I commit an infraction of the School rules. Student Signature: Date: Page 2 of 2
PUBLIC RELATIONS, WAIVER AND RELEASE OF LIABILITY, AND PARENTAL CONSENT FOR Ebenezer ALIVE! DUE May 24, 2013 Yes, my child can be in the Ebenezer ALIVE! video and/ or pictures for a brochure that will be developed in order to inform others about the new education program. I authorize Ebenezer ALIVE! and New Ebenezer Retreat Center to use photographs and videos in any manner deemed advantageous to New Ebenezer by its representatives. I acknowledge that all photos (including audio) become the sole and exclusive property of New Ebenezer. Signature of Parent/Guardian Date * * * * * * * * * * * * New Ebenezer Retreat Center Waiver and Release of Liability and Parental Consent I hereby agree and consent to my child s participation in Ebenezer ALIVE! provided by or on behalf of New Ebenezer Retreat and Conference Center for the age group in question. I, on behalf of my child, hereby waive, release and discharge New Ebenezer, its agents and employees, of any claim whatsoever that is not the direct result of active, foreseeable negligence on the part of New Ebenezer and its respective agents and employees. I further waive, release and discharge New Ebenezer from any claim whatsoever on account of first aid, treatment or service rendered to my child as a result of my child s participation in the Ebenezer ALIVE! Education Program. I have read the above waiver and release of liability and parental consent and by signing it agree that it is my expressed intent to exempt and relieve New Ebenezer from liability for personal injury, property damage, or wrongful death other than such claims that arise as the direct result of active, foreseeable negligence. Name of Child Age Child s Mailing Address City State Zip Code Signature of Parent or Guardian Date School or Group Name 2013-14 STUDENT HANDOUT 13
Medical Authorization Form A School Student s Name Date of Birth Grade Gender Race (for reporting purposes only): Black Oriental Spanish White Native American Multi Raced other Home Address: City State Zip Correct medical information is needed in case of an emergency. information you feel is applicable. Please complete the blanks below and submit other 1. Date of last physical examination 2. Drug Allergies 3. Other Allergies (such as a Food, Bees, etc.) 4. Date of last Tetanus Immunization 5. Is there a history of Heart Condition, Diabetes, Asthma, Epilepsy, Rheumatic Fever? 6. Are there any physical restrictions? If yes, please describe 7. Describe any recent illness or injury: 8. Are you taking any medications (prescription or over the counter) at the present time? Yes No If answer is yes, you must fill out Form B and attach. NOTE: If a child has a medical condition, it is requested that the child wear a medical alert bracelet/necklace. Name of Family Physician: Phone: INSURANCE COVERAGE INFORMATION I understand that should a health problem arise, I will be notified, but that if I cannot be reached by phone, such medical treatment, including surgery, as deemed necessary by competent medical personnel could be rendered; that necessary information may be released for insurance purposes. Ebenezer ALIVE! Program - New Ebenezer Retreat Center Event or Activity Signature - Parent Guardian Date of Event Names of 3 persons other than your parents or guardians that may be contacted for consent or advice in the case of any emergency. Name Phone Name Phone Name Phone (2013-14) STUDENT HANDOUT 14
Medical Form B Complete this form if prescription medications are being taken by the student at the time of the event. ADDENDUM TO THE MEDICAL AUTHORIZATION / MEDICATIONS School Student s Name Phone: Evening Day Other Address: City State Zip Name of Medication The medication must be in original prescription bottle or container! (Not in pill packs) **IF YOUR CHILD NEEDS OVER THE COUNTER MEDICINES SUCH AS TYLENOL, ADVIL, MOTRIN, ETC. PLEASE SEND IN ORIGINAL BOTTLE AND INCLUDE INSTRUCTIONS ON DOSAGE **YOUR CHILD MUST GIVE ADULT LEADER ANY MEDICINES WHETHER OVER THE COUNTER OR PRESCRIPTION What Illness/Condition is this medication intended for: MEDICATION IS TO BE ADMINISTERED BY SCHOOL PERSONNEL ONLY Dosage: Special Instructions: Other Information (if applicable) Date(s) to administer: From To Refrigeration? Yes No Prescribing Doctor s name: Phone Event: Ebenezer ALIVE! Program Date: Signature of Parent-Guardian Date 2013-14 STUDENT HANDOUT 15