Login | Staff Email | Contact Us
HomebuttonOverviewbuttonAcademicsbuttonParentinfobuttonStudentlifebuttonAdmissionsbutton

Registration Emergency Form

Fill out the following form and submit it or download registration form here and mail it in

St. Michael's Episcopal Day School Student Registration and Emergency
2010-2011 School Year

Grade Date of Birth / / Male Female
Student Last Name First Name Middle Name
Address City State Zipcode
Mother or Guardian Home Address Home Phone
Business Name Pager Business Phone
Business Address/Zip Cell Phone E-Mail
Father or Guardian Home Address Home Phone
Business Name Pager Business Phone
Business Address/Zip Cell Phone E-Mail
If the school cannot contact parent, name a relative or friend who may be called if the child is ill.
Relative or Friend Address Phone
Relative or Friend Address Phone
Physician Address Phone
Medical Insurance Co. I.D. Number Hospital Preference


Medical Treatment Authorization

In the event of an accident or other emergency, when a parent is unavailable I hereby authorize a representative of the school to make such arrangments as considered necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named above to undertake such care and treatment of my child as necessary.

In the event said physician is not available at the time, I authorize such care and treatment to be performed by any licensed physician or surgeon.
 I give my permission for authorized staff of St. Michael's Episcopal Day School to administer Tylenol according to the age prescribed dose.


I give my permission for my child to participate in all activities which are part of the school program, including field trips and excursions away from premises, and inclusion in marketing materials including web site, publications and videos, and hold the school not responsible for accidents or injuries not directly related to its own negligence.
Date September 7th, 2010
*Because we use e-mail for correspondence such as Wednesday Letters, it is important that we have an e-mail address for each family.

PLEASE CHECK THE FOLLOWING ITEMS IF THEY PERTAIN TO YOUR CHILD

Check here if there are NO KNOWN health problems Allergies Allergic reaction/bee stings
Asthma
EYES Yes No
Wears Glasses To be worn at all times
Wears Contacts To be worn at all times
Describe:
Are any of the above life threatening?
Requires preferential seating List medication prescribed:
Date of last eye examination Current dosage
Under care of Dr. For (diagnosis)
Comments Does the drug need to be taken during school hours?
Prescribed by Dr. Ph. no.
EARS Has a physical condition which limits participation in:
Has a hearing problem classroom activities physical education
Has tubes in ears Please explain
Uses hearing aid
Requires preferential seating
PLEASE READ
The Education Code (12020) requires parents to inform the
school of medications being taken upon a physician's
prescription and authorizes the school nurse to contact the
physician with parental consent. Students must be full
immunized and have a Health Examination on record in
accordance with State Health Department regulations.
Waivers will not be accepted.
Under care of Dr.
Comments
GENERAL HEALTH
Has the following condition(s): Motion Sickness
Epilepsy Fainting spells
Diabetes Hyperactive (ADD)
Heart Condition Migraines


St. Michael's Episcopal Day School . 2140 Mission Ave. . Carmichael, CA 95608 . 916-485-3418