Student Emergency Information: 2020-2021

Student Emergency Information: 2020-2021

By filling out the TLC Student Emergency and Medical forms and sending my child to school, I/we as the parent/guardian acknowledges that student enrollment at The Learning Center for the Deaf is voluntary and being done during a global pandemic. While TLC is taking every precaution and developing a thorough Reopening Action Plan that addresses the health and safety of our students, families, staff and visitors, I/we understand the risk involved in choosing to send my child(ren) for in-person schooling.
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Please Select:*

Marie Philip SchoolWalden School
Your Child's Grade*
Your Child's Gender*

MaleFemaleNon Binary
Does Your Child Have Health Insurance?*

YesNo
Health Insurance Provider:
Health Insurance Policy Number
Dental Insurance Provider
Dental Insurance Policy Number

TYLENOL/ADVIL PERMISSION
The school nurse keeps several basic medications on hand to administer to students to meet their health and safety needs. Please check each box next to the medication you AUTHORIZE the school nurse to administer to your child:*

AdvilTylenolBacitracin OintmentSunblockCough DropsNone
If you do NOT authorize the school nurse to administer any medication to your child, please check the box below.

Opt out of all medication
I give permission to the school nurse to share information relevant to my child’s health condition with appropriate school and/or emergency medical personnel when needed to meet my child’s health and safety needs. I give permission to exchange information with my child’s primary care physician for the purpose of referral, diagnosis and treatment. I give permission for emergency medical treatment.
Signature (Use Finger on Smart Phone or Use Mouse to Sign):

Clear
Parent/Guardian Name:*

First NameLast Name
Physician's name:

First NameLast Name
Physician's Phone Number

Area CodePhone Number
Dentist's name:

First NameLast Name
Dentist's Phone Number

Area CodePhone Number

AUTHORIZATION AND PERMISSION TO FIELD TRIPS
I, the parent guardian of:
Student Name:*

First NameLast Name
authorize Marie Philip/Walden School to take my child on field trips utilizing school vehicles or other school approved means of transportation:*

YESNO
Signature (Use Finger on Smart Phone or Use Mouse to Sign):

Clear

PARENT/GUARDIAN PERMISSION TO PARTICIPATE IN PHYSICAL EDUCATION AND ATHLETICS PROGRAM
My child may participate fully in The Learning Center for the Deaf/Marie Philip School/Walden School’s Physical Education Program:*

YESNO
If "No", please list restrictions:
My child may participate fully in The Learning Center for the Deaf/Marie Philip School/Walden School’s Athletics Program:*

YESNO
If "No", please list restrictions:
Parent/Guardian Name:*

First NameLast Name
Medical documentation of participant’s restrictions is required.

In order to be accepted onto a team and participate in practice and sports events, a student is required to have a current physical exam, less than one year old, that states he/she may participate fully in sports and specifies any limitations.

EMERGENCY CONTACT INFORMATION