2017-18 Back-to-School Forms JrK Please complete all included forms and submit to the front desk. Scheduled paperwork turn in times are as follows: July 17 through 21st, between 8am-5pm: Last names A-M July 24th through 28th, between 8am-5pm: Last names N-Z Make ups: Friday the 4th between 3-6pm or by appointment during the week of July 31st
POLICY ACKNOWLEDGEMENT FORM My child and I have received a copy of the Merryhill Handbook including the Technology Policies and Procedures. I understand that the handbook contains information that my child and I will need during the school year. Signature of Student: Signature of Parent: Date: PHOTO RELEASE FORM GENERAL RELEASE: This is a general release made on July, 2017 between Nobel Learning Communities, Inc., hereinafter referred to as I, and (Parent/Guardian name). IT IS HEREBY AGREED AS FOLLOWS: That I, the undersigned, for good and valuable consideration, the receipt of which is hereby acknowledged, do for myself and on behalf of my child or legal ward, hereby grant to Nobel Learning Communities, Inc. and its parent corporations, subsidiaries, affiliates and other related companies (collectively, NLCI ), and all of its or their respective officers, directors, agents, employees, partners, licensees, shareholders, predecessors, successors and assigns, solely for NLCI promotional purposes (the Permitted Use ), the right to use and publish the picture, portrait, likeness and/or testimonial of (Child s Name). I acknowledge that the Permitted Use includes any medium now or hereafter known, without restriction as to manner, frequency or duration of usage, and shall be without compensation of any kind. I further agree that my child s picture, portrait, likeness and/or testimonial may be used with whatever visuals, copy or other elements NLCI may determine, subject to the terms of this general release, and I agree that all such materials produced hereunder are and will remain the sole and exclusive property of NLCI and will not have to be reviewed with me prior to their use, and that NLCI will have no liability to me resulting from the Permitted Use. I acknowledge that if in the future I submit a written withdrawal of the foregoing permission to the school s principal, such withdrawal of permission will pertain only to future or new materials, and will not terminate the Permitted Use with respect to any material previously produced or used. IN WITNESS WHEREOF, I have caused this general release to be duly executed as of the day and year first above written. Parent Signature Date
STUDENT EMERGENCY/MEDICAL INFORMATION CARD (Must be completed each school year and submitted prior to the first day or school) STUDENT INFORMATION: Student Name: Grade: Age: Birthdate: Home Address: Primary Contact Phone: Secondary Phone: Ethnicity: Resides with: PARENT/GUARDIAN INFORMATION: Parent/Guardian Name: Employer: Position: Work Address: Cell Phone: Work Phone: Email Address: Parent/Guardian Name: Employer: Position: Work Address: Cell Phone: Work Phone: Email Address: I agree to have the following information included in a class directory which will be shared with PTSO and other families in your child's class. Phone: Email: I request to have my individual 2017 year-end tax statement provided to me via email. *Statements will only be emailed per request. EMERGENCY CONTACTS & PICK UP AUTHORIZATION: In case child listed above needs to be picked up by someone other than myself, becomes ill, or is injured at school and I cannot be contacted, the school authorities have my permission to grant and release my child to the custody of one of the following: Emergency Contact #1 Name: Relationship: Contact Number: Emergency Contact #2 Name: Relationship: Contact Number: Emergency Contact #3 Name: Relationship: Contact Number:
MEDICAL INFORMATION: Insurance Name & Member Number: Health Care Provider Phone Number: My child has: No known medical conditions Major medical issues*: Medications taken regularly: Allergies/Allergic* to: Treatment: *For severe allergic reactions or other more severe medical issues, an accommodation plan is required along with required forms outlining instructions for emergency situations (i.e.: administering an epi-pen injection). See below. ALLERGY PRECAUTIONS (if applicable): The allergy can be prevented by: Peanut allergies: My child has an airborne peanut allergy and cannot be near, touch, or ingest peanuts. My child can be in a facility with peanuts but cannot ingest them. ALLERGIC REACTIONS (if applicable): Reaction symptoms: Date of last reaction: Action taken: Requires epinephrine *ALLERGIC REACTION RESPONSES: If your child has a severe food allergy*, click here to access the required action plan form. This must be submitted with medication prior to the start of school. Please refer to the Handbook section on medication. OTHER CONDITIONS - If your child has a medical condition* requiring specific administration of medication or emergency action plans, procedures must be in writing from the doctor and provided to the school prior to the first day of school. *These circumstances require accommodations on the part of the school. An accommodation action plan will be created by the school and requires parent signature. CONSENT: I give my consent for the school to follow the procedures outlined above. If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one. I give my consent for the school to take appropriate action for the safety and welfare of my child. Parent/Guardian Signature (Required) Date
STATE LICENSING PAPERWORK (ADDITIONAL REQUIREMENTS) (Required prior to child s first day. If previously submitted for summer 2017, it is not required to resubmit) PHYSICIAN S REPORT - Click here to access form. Complete form, print, and submit to front office with physician signature. IDENTIFICATION & EMERGENCY INFORMATION - Click here to access form. Complete form, print, and submit to the front office. CHILD CARE CENTER NOTIFICATION OF PARENTS RIGHTS - Click here to access form. Enter Licensing Office Name as Department of Social Services Community Care License. Enter Licensing Office Address as 2525 Natomas Park Drive, Suite 250, Sacramento, CA and office telephone number as 916-263-5744. Print and submit form to front office. PERSONAL RIGHTS - Click here to access form. Complete form, print, and submit to front office. Enter licensing agency information as follows: Enter Licensing Office Name as Department of Social Services Community Care License. Enter Licensing Office Address as 2525 Natomas Park Drive, Suite 250, Sacramento, CA and office telephone number as 916-263-5744. CONSENT FOR MEDICAL TREATMENT - Click here to access form. Complete form, print, and submit form to front office.
FIELD TRIP PERMISSION My child,, has permission to attend all field trips that occur during the 2017-18 school year, unless notification is given in writing by the parent/guardian. Please check line 1 or line 2 to indicate the action desired in the event of an accident or emergency. 1. In the event of an accident or other emergency, when a parent/guardian is unavailable, I hereby authorize a representative of the school to make the arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is not available at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon. Physician Name: Phone Number: Insurance Carrier: ID Number: 2. I do not choose the above statement and desire the following action: The undersigned hereby agrees to bear all costs as a result of the foregoing. FIELD TRIP BUS POLICIES & TRANSPORTATION SAFETY PLAN AGREEMENT: MUST BE SIGNED FOR ALL STUDENTS The safety of all Merryhill students and parents is our main objective and we appreciate your help in achieving that goal and insuring we comply fully with California law. I, the parent/ guardian of have read and understand the Transportation Safety Plan for Merryhill Schools. I understand that failure to comply with the bus safety and behavior rules may result in disciplinary action up to and including the suspension/expulsion of bus riding privileges for field trips. Printed Parent/Guardian Name: Parent/Guardian Signature:
Optional form: Complete if your child will be riding a bus route to and/or from school. MERRYHILL SCHOOLS ROUTE BUS RIDER POLICY & PROCEDURE ACKNOWLEDGEMENT FORM (Millcreek and Harbour Point route riders only) I, the parent/guardian of, have read the Merryhill School Transportation Safety Plan and understand the policies regarding pick-up and drop-off procedures outlined within. I understand that failure to comply with this policy may result in disciplinary action up to and including the suspension of bus riding privileges. Additionally (please initial next to each bullet point item below): For all Millcreek and Harbour Point route riders: I have read and understand the policies and procedures governing the Street Side Bus Stop and Care Campus Bus Stop locations. I understand that no child will be allowed to cross the parking lot unescorted by me, the parent, for any reason. I understand that circumstances may occur that are outside the control of the Merryhill Transportation department, which may result in a late bus, or suspension of bus service in part or completely. For Street Side Bus Stop riders: I understand that it is my responsibility to escort my child TO THE BUS DOOR for pickup, and escort my child FROM THE BUS DOOR upon arrival. I understand that the transfer of care for my child, and the transfer of responsibility for my child, will occur at the bus door ONLY AFTER the bus driver checks in or checks out my student. I understand that I must be waiting and ready to deliver my child AND retrieve my child when the bus arrives. I understand that the bus will not wait for me, the parent, if I am late. In such an instance, my child will be sent to the B/A Care campus for pickup. I understand that if my child is sent into a B/A Care campus, I may be subject to disciplinary action, including a fees and/or suspension of bus riding privileges. My child will ride the following bus (mark one route): Harbour Point Millcreek Daily Bus Riders: I accept that the behavior and safety of my student(s) is my sole responsibility while waiting for and approaching the bus to load/unload for a street side bus stop. I acknowledge the appropriate time for my child to be at the bus stop or inside the care campus is 5 minutes prior to bus arrival. Parent/Guardian Name: Parent/Guardian Signature: Date:
Optional form: Complete to set up automatic payment for tuition. No processing fee.
Optional form: Complete if prefer to pay with credit card.
SPIRIT WEAR ORDER FORM 2017-18 Student s Name Grade Payment Form: Cash Check Credit Card (on file) ITEM SIZE: YS, YM, YL, YXL AS, AM, AL, AXL PRICE QTY TOTAL 1. Uniform spirit socks Availability based on current sizes in stock $15 per pair 2. Class color tee (required for every student, keep same color through 8th grade) 3. Crew neck, navy sweatshirt (YXS-AXL) (YS-AL) $15 $25 4. Zip up, hooded, light grey sweatshirt (YS-AXL) $35 5. Hooded, dark grey sweatshirt (YS-AXL) $30 6. Logo embroidered, adult athletic 1/2 zip (AS-AXL) $40 7. Long sleeve tee Availability based on current sizes in stock $20 8. 8 Plush FIERCE the Mustang $15 Students will receive items not in stock in their classrooms/homerooms upon delivery. Class Color Shirts: JrK & 4th: blue K & 5th: yellow 1st & 6th: red 2nd & 7th: orange 3rd & 8th: green