Shepherd Elementary School Star Achievers ‐ Before and After School Program Registration ‐ Medical Consent Form 2014/15 School Year sesstarachievers@gmail.com (202) 465‐0514 Student Information – Please fill out one form for each child (no need to duplicate info if already provided) Student Name: Last _________________________First _____________________Middle ____ Student Address: __________________________________________City _______________State _____ Zip _____________ Grade level _____ Age _______ DOB ________Height ______ Weight _____Gender M __ F ___ Hair Color________
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ONE TO BE REGISTERED FOR STAR ACHIEVERS:Service Requested: Morning Only: ______ (7:30 – 8:30am) $65 per month tuition x 9 months Afternoon Only:________(3:15pm – 6:30pm) $245 per month tuition x 9 months Morning and Afternoon: _______ $279 per month tuition x 9 months Primary Parent/Guardian FIRST PERSON TO BE CONTACTED IN AN EMERGENCY or if child left in care after 6:30pm Last Name _______________________________ First Name ____________________________ E‐MAIL (required):________________________________ Telephone: Home # _________________ Work # _______________ Cell # ___________________ Secondary Parent/Guardian SECOND TO BE CONTACTED IN AN EMERGENCY Last Name ____________________________ First Name ____________________________ Telephone: Home ____________________ Work __________________ Cell: _________________ E‐MAIL(required):________________________________________________________ Authorized Pick‐Ups: Permission is given for my child to be released from the program to the following individuals (in addition to the above stated parent/guardian). Valid photo ID required, students will not be dismissed to any one without proper ID. All relatives/persons who will pick‐up my child, such as tutors, babysitters, etc must be listed here: NO EXCEPTIONS. STUDENTS MAY NOT BE RELEASED TO ANYONE UNDER 16 YEARS OF AGE without written consent of parent. Name __________________________________ Relationship ____________________________ Address _________________________________ Phone ________________________________ Name __________________________________ Relationship ____________________________ Address ________________________________ Phone_________________________________ Name __________________________________ Relationship ____________________________ Address ________________________________ Phone_________________________________
2 To add to this list of those authorized to pick up your child AFTER you have registered, please email information to sesstarachievers@gmail.com or call (202) 465‐0514. Information may NOT be updated by calling the school office. Emergency Contact : Must provide 2 additional names other than parents. List in order they are to be contacted. Note: Parents will be contacted first. Name _________________________________ Relationship to Child ____________________________ Tele: Home ___________________________ Work ______________________ Cell: _______________________ Name _________________________________ Relationship to Child ____________________________ Tele: Home ___________________________ Work ______________________ Cell: _______________________ I am/my child is covered by medical insurance ____ I am not/my child is not covered by medical insurance _______ Insurance Company: _____________________ Policy No: ____________________Insurance Co phone #: _______________________ Policy Holder’s name: _________________________ Effective date: ___________ Student Participation Permission – Consent for Medical Treatment ‐ Consent for Release to Media Participation in the Star achievers before and aftercare program at Shepherd Elementary (hereinafter known as SESSA) includes physical education, dance and other classes and activities, both inside and on the playground. Some activities include use of equipment. I hereby acknowledge that participation in these classes and uses of said equipment carry some risk of injury or severe injury for my child. I hereby give my consent for the above‐named student to participate in SESSA activities including use of the playground, lower field adjacent to Shepherd Elementary School and the one‐block area of 7800 14th Street NW surrounding Shepherd Elementary School. In addition, I/We agree to comply with all the rules, regulations and policies that govern this program and that are found in the Star Achievers Handbook and on the Shepherd Website. In addition I/We agree to the financial obligation and terms of payment for this program and understand that all unpaid balances will result in late fees and/or possible termination from program. I/We also understand any past due balances may be submitted to a collection agency and subsequent collection agency fees applied to the open balances. I authorize the directors to act for me according to their best judgment in an emergency requiring medical attention, including covering the cost of emergency ambulance services. Prior to participation in the SESSA Program parents/guardians of students are required to sign this form and are deemed to have waived all claims against Shepherd Elementary School Star Achievers, its employees and Board of Directors, and the DC Public Schools, its employees and the District of Columbia for any injury, accident, or illness occurring during or by reason of participation in the Program. I accept the responsibility to inform the school of any future change of this information. I, the parent or guardian of the enrolled student, hereby agree that SESSA or its representative may videotape, photograph and voice record the herein named student for media, marketing or promotional purposes related to his or her participation in the Program. This may include posting online, photo displays or other promotional opportunities. I HAVE READ THIS FORM AND UNDERSTAND THE RULES CONTAINED HEREIN, AND THE INFORMATION SUPPLIED IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Signature of Parent or Legal Guardian Date: ________________ Printed Name of Parent or Legal Guardian: _________________________________ I hereby give permission for SESSA to share my contact information with the Shepherd Elementary PTA: Yes or No
Shepherd Elementary School Star Achievers ‐ Before and After School Special Medical/Behavioral Needs Form 2014/15 School Year sesstarachievers@gmail.com (202) 465‐0514 ******IF YOUR CHILD HAS ANY SPECIAL NEEDS, YOU MUST COMPLETE AND SUBMIT THIS FORM PRIOR TO YOUR CHILD ATTENDING BEFORE OR AFTERCARE ****** Name of student (Last, First, MI) ______________________________________________ Parent to be contacted with questions/emergencies regarding special medical/behavioral need: Name: __________________ Phone Number (to be contacted between 3:30 and 6:30pm): ________________ Does your child have any of the following special needs that would impact participation in SESSA Program activities? Check all that apply: Anemia __ Sickle Cell Trait ___ Diabetes__ Epilepsy ____ Seizure Disorder ____ High Blood Pressure _____ Previous Concussion/Head injuries ____ Behavioral/Developmental issues: _____ List all that apply here, along with interventions used during the school day to assist your child: Allergies ____ If yes, complete the following: My child’s known allergies (Please indicate mild, moderate, severe for each listed) 1. 2. 3. ASTHMA If yes, complete the following: Asthma Severity: Intermittent: ____ Persistent: Mild _____ Moderate ____ Severe ___ Identified Asthma triggers: Colds ___ Pollen ____ Dust ____ Strong odors ____ Mold/Moisture ____ Pests (cockroaches or rodents) _____ stress/emotions ____ Gastroesophageal reflux _____ Exercise _____ Season: Fall ____ Winter ____ Spring ____ Summer _____ Can your child participate fully in all Star Achievers Programs? Y or N If not, what are your child’s limitations?
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If your child requires any medication to be administered during before or aftercare hours, you must complete the appropriate Medication Consent and Provider Order. If you have already completed a copy of the similar DCPS form, please submit a copy to Star Achievers via email: sesstarachievers@gmail.com or call (202) 465‐0514 to submit in person.
ALLERGY Medication Consent and Provider Order Applicable for the school year: 2014/2015 Medical condition for which your child needs medication: ____________________________________________ List here all control medicines or rescue medicine your child should take during Shepherd Elementary School Star Achievers (SESSA) Program hours and under what conditions: Healthcare Provider’s initials here: _________ This student was trained and is capable to self‐administer medication to the student. __________This student is not approved to self‐medicate. Healthcare Providers Name (Printed)________________________ Healthcare Provider’s Signature: __________________________________ Date: _____ ____ As the responsible person, I hereby authorize a trained SESSA or DCPS school employee to administer __________________________________________________ medication to the student. ___ As the responsible person, I hereby authorize this student to possess and self‐administer ________________________________________medication. I hereby acknowledge that the District, the school, its employees and agents shall be immune from civil liability for acts or omissions under DC Law 17‐107. I further agree to supply to SESSA the appropriate dosage and non‐expired medication to store and administer as noted above. These medications listed below are prescribed by a physician as noted on the label, and are:
EipPen Jr (0.15mg) ___ EpiPen (0.3mg) ____ Other medication: ____________
I also hereby acknowledge that if I do not supply the medications prescribed for my child to be administered in a medical emergency associated with his or her allergies the SESSA or DCPS staff will call 911 and seek other appropriate medical care and that SESSA does not have any medications to administer other than those provided by me pursuant to this agreement.
Responsible person’s name printed: ________________________
If your child requires any medication to be administered during before or aftercare hours, you must complete the appropriate Medication Consent and Provider Order. If you have already completed a copy of the similar DCPS form, please submit a copy to Star Achievers via email: sesstarachievers@gmail.com or call (202) 465‐0514 to submit in person.
ASTHMA Medication Consent and Provider Order: Applicable for the school year: 2014/15 Medical condition for which your child needs medication: ____________________________________________ List here all control medicines or rescue medicine your child should take during Shepherd Elementary School Star Achievers (SESSA) Program hours and under what conditions: Healthcare Provider’s Initials here: _________ This student was trained and is capable to self‐administer medication to the student ________ This student is not approved to self‐medicate. Healthcare Providers Name (Printed)_________________________ Healthcare Provider’s Signature: __________________________________ Date: _____ ____ As the responsible person, I hereby authorize a trained SESSA or DCPS school employee to administer ______________________________medication to the student. ___ As the responsible person, I hereby authorize this student to possess and self‐administer ______________________________ medication. I hereby acknowledge that the District, the school, its employees and agents shall be immune from civil liability for acts or omissions under DC Law 17‐107. I further agree to supply to SESSA the appropriate dosage and non‐expired medication to store and administer as noted above. These medications listed below are prescribed by a physician as noted on the label, and are: 1. 2. 3. I also hereby acknowledge that if I do not supply the medications prescribed for my child to be administered in a medical emergency associated with his or her asthma the SESSA or DCPS staff will call 911 and seek other appropriate medical care and that SESSA does not have any medications to administerother than those provided by me pursuant to this agreement. Responsible person’s name printed: ________________________ Responsible person’s signature: _______________________ Date: __________
