All Applications: Completed Registration Application Parent Statement of Agreement Parental Consent for Use of Photos Food and Nutrition Policies Medical Information Medical Authorization & Release Emergency Contact & Pick-up Authorization 4C-Eligibility Certificate (VPK students only)

Orange County Online Application New Student Applications: Copy of Birth Certificate Certificate of Immunization (DH form 680-Orginal only) Proof of Physical Examination within the last year (DH form 3040-Original only)

Trinity Christian School

VPK Only Enrollment Requirements Checklist

During the 2009 legislative session, a new law was passed that requires child care facilities, family day care homes and large family child care homes provide parents with information detailing the causes, symptoms, and transmission of the influenza virus (the flu) every year during August and September.My signature below verifies receipt of the brochure on Influenza Virus, The Flu, A Guide to Parents:

Name: ________________________________

Child’s Name: ________________________

Date Received: _______________________

Signature: ____________________________

Please complete and return this portion of the brochure to your child care provider, in order for them to maintain it in their records.

What should I do if my child gets sick?Consult your doctor and make sure your child gets plenty of rest and drinks a lot of fluids. Never give aspirin or medicine that has aspirin in it to children or teenagers who may have the flu.

CAll oR TAke youR ChIlD To A DoCToR RIGhT AWAy IF youR ChIlD:

• Has a high fever or fever that lasts a long time• Has trouble breathing or breathes fast• Has skin that looks blue• Is not drinking enough• Seems confused, will not wake up, does not

want to be held, or has seizures (uncontrolled shaking)

• Gets better but then worse again• Has other conditions (like heart or lung

disease, diabetes) that get worse

What can I do to prevent the spread of germs?The main way that the flu spreads is in respiratory droplets from coughing and sneezing. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and infect someone nearby. Though much less frequent, the flu may also spread through indirect contact with contaminated hands and articles soiled with nose and throat secretions. To prevent the spread of germs:

• Wash hands often with soap and water.

• Cover mouth/nose during coughs and sneezes. If you don’t have a tissue, cough or sneeze into your upper sleeve, not your hands.

• Limit contact with people who show signs of illness.

• Keep hands away from the face. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.

When should my child stay home from child care?A person may be contagious and able to spread the virus from 1 day before showing symptoms to up to 5 days after getting sick. The time frame could be longer in children and in people who don’t fight disease well (people with weakened immune systems). When sick, your child should stay at home to rest and to avoid giving the flu to other children and should not return to child care or other group setting until his or her temperature has been normal and has been sign and symptom free for a period of 24 hours.

For additional helpful information about the dangers of the flu and how to protect your child, visit: http://www.cdc.gov/flu/ or http://www.immunizeflorida.org/

how can I protect my child from the flu? A flu vaccine is the best way to protect against the flu. Because the flu virus changes year to year, annual vaccination against the flu is recommended. The CDC recommends that all children from the ages of 6 months up to their 19th birthday receive a flu vaccine every fall or winter (children receiving a vaccine for the first time require two doses). You also can protect your child by receiving a flu vaccine yourself.

INF

lu

eN

zA

VIR

uS

INF

lu

eN

zA

VIR

uS

“The Flu” A Guide

for Parents

For additional information, please visit www.myflorida.com/childcare or contact your

local licensing office below:

This brochure was created by the Department of Children and Families in consultation with the Department of Health.

CF/PI 175-70, June 2009

What is the influenza (flu) virus?Influenza (“the flu”) is caused by a virus which infects the nose, throat, and lungs. According to the US Center for Disease Control and Prevention (CDC), the flu is more dangerous than the common cold for children. Unlike the common cold, the flu can cause severe illness and life threatening complications in many people. Children under 5 who have the flu commonly need medical care. Severe flu complications are most common in children younger than 2 years old. Flu season can begin as early as October and last as late as May.

how can I tell if my child has a cold, or the flu? Most people with the flu feel tired and have fever, headache, dry cough, sore throat, runny or stuffy nose, and sore muscles. Some people, especially children, may also have stomach problems and diarrhea. Because the flu and colds have similar symptoms, it can be difficult to tell the difference between them based on symptoms alone. In general, the flu is worse than the common cold, and symptoms such as fever, body aches, extreme tiredness, and dry cough are more common and intense. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations.

Know Your Child Care

Facility

MyFLFamilies.com/ChildCare

CF/PI 175-24, 03/2014This brochure was created by the

Florida Department of Children and Families, Office of Child Care Regulation and Background Screening

pursuant to s. 402.3125(5), F.S.,

To report suspected or actual cases of child abuse or neglect, please call the

Florida Abuse Hotline at 1-800-962-2873.

This child care facility is licensed accordingto the minimum licensure standards included in section 402.305, Florida Statutes(F.S.), and Chapter 65C-22, Florida Administrative Code (F.A.C.). License Number: C09OR0932 License Issued on 02/24/19License Expires on 02/24/20For more information regarding the compliance history of this child care provider, please visit: MyFLFamilies.com/childcare

Office of Child Care Regulationand Background Screening

Office of Child Care Regulationand Background Screening

More information

and free resources:

MyFLFamilies.com/ChildCare

A parent’s role in quality child care is vital: ☐ Inquire about the qualifications and

experience of child care staff, as well as staff turnover.

☐ Know the facility’s policies and procedures.

☐ Communicate directly with caregivers. ☐ Visit and observe the facility. ☐ Participate in special activities,

meetings, and conferences. ☐ Talk to your child about their daily

experiences in child care. ☐ Arrange alternate care for their child

when they are sick. ☐ Familiarize yourself with the child care

standards used to license the child care facility.

Parent’s Role

Quality Caregivers ☐ Are friendly and eager to care for children. ☐ Accept family cultural and ethnic differences. ☐ Are warm, understanding, encouraging, and

responsive to each child’s individual needs. ☐ Use a pleasant tone of voice and freqently hold,

cuddle, and talk to the children. ☐ Help children manage their behavior in a positive,

constructive, and non-threatening manner. ☐ Allow children to play alone or in small groups. ☐ Are attentive to and interact with the children. ☐ Provide stimulating, interesting, and educational

activities. ☐ Demonstrate knowledge of social and emotional

needs and developmental tasks for all children. ☐ Communicate with parents.

Quality Environments ☐ Are clean, safe, inviting, comfortable, child-friendly. ☐ Provide easy access to age-appropriate toys. ☐ Display children’s activities and creations. ☐ Provide a safe and secure environment that fosters

the growing independence of all children.

Quality Child CareQuality child care offers healthy, social, andeducational experiences under qualified supervisionin a safe, nurturing, and stimulating environment. Children in these settings participate in daily, age-appropriate activities that help develop essential skills, build independence and instill self-respect. When evaluating the quality of a child care setting, the following indicators should be considered:

Quality Activities ☐ Are children initiated and teacher facilitated. ☐ Include social interchanges with all children. ☐ Are expressive including play, painting, drawing,

story telling, music, dancing, and other varied activities.

☐ Include exercise and coordination development. ☐ Include free play and organized activities. ☐ Include opportunities for all children to read, be

creative, explore, and problem-solve.

Every licensed child care facility must meetthe minimum state child care licensing standardspursuant to s. 402.305, F.S., and ch.65C-22, F.A.C., which include, but are not limitedto, the following:

☐ Valid license posted for parents to see. ☐ All staff appropriately screened. ☐ Maintain appropriate transportation vehicles

(if transportation is provided). ☐ Provide parents with written disciplinary practices

used by the facility. ☐ Provide access to the facility during normal hours

of operation. ☐ Maintain minimum staff-to-child ratios:

Physical Environment ☐ Maintain sufficient usable indoor floor space

for playing, working, and napping. ☐ Provide space that is clean and free of litter

and other hazards. ☐ Maintain sufficient lighting and inside

temperatures. ☐ Equipped with age and developmentally

appropriate toys. ☐ Provide appropriate bathroom facilities and

other furnishings. ☐ Provide isolation area for children who

become ill. ☐ Practice proper hand washing, toileting,

and diapering activities.

Health Related Requirements ☐ Emergency procedures that include:

• Posting Florida Abuse Hotline numberalong with other emergency numbers.

• Staff trained in first aid and Infant/ChildCPR on the premises at all times.

• Fully stocked first aid kit.• A working fire extinguisher and

documented monthly fire drills withchildren and staff.

☐ Medication and hazardous materials are inaccessible and out of children’s reach.

Training Requirements ☐ 40-hour introductory child care training. ☐ 10-hour in-service training annually. ☐ 0.5 continuing education unit of approved

training or 5 clock hours of training in early literacy and language development.

☐ Director Credential for all facility directors.

General Requirements

Age of Child Child: Teacher Ratio

Infant 1 year old 2 year old 3 year old 4 year old 5 year old and up

4:16:111:115:120:125:1

Food and Nutrition ☐ Post a meal and snack menu that pro-

vides daily nutritional needs of the chil-dren (if meals are provided).

Record Keeping ☐ Maintain accurate records that include:

• Children’s health exam/immunizationrecord.

• Medication records.• Enrollment information.• Personnel records.• Daily attendance.• Accidents and incidents.• Parental permission for field trips and

administration of medications.

Trinity Christian School 1022 S. Orange Blossom Trail

Apopka, FL 32703

DCF License #C09OR0932

OFFICE USE ONLY

Date Rec’d.

Application Fee Employee Tuition

Book & Activity Fee Tuition

Eligibility Certificate

Start Date

Teacher

STUDENT INFORMATION

LAST NAME

FIRST NAME MI

Goes by

Date of Birth

Male Female

Caucasian African-American Asian

Hispanic Indian Other

BILLING INFORMATION BILL TO

Address

City St Zip

Home Phone

Email (required)

FAMILY INFORMATION Child primarily lives with:

Both Parents together Legal Guardian

Mother Father Stepmother Stepfather

Who has legal custody? (Office must have a copy of custody papers on file.)

FATHER Title: (Mr., Dr., Rev., other ) Name Address City State Zip

E-mail

Home Phone

Cell Phone

Work Phone

Occupation/Title

Employer

MOTHER Title: (Mrs., Ms., Dr., other ) Name Address City State Zip

E-mail

Home Phone

Cell Phone

Work Phone

Occupation/Title

Employer

CHURCH INFORMATION Are you or your child a member of a church? Yes No Church Name

Denomination

PREVIOUS SCHOOL INFORMATION School Address

City St Zip

Phone Number

Any grade repeated?

Ever dismissed/suspended from any school?

Yes No

Reason for leaving ___________________________

__________________________________________

(If yes, explain on separate sheet and attach to application.)

APPLICATION

2020-21 School Year

NEW RETURNING

VPK only M-F (8-11)

VPK only M/W/F (8-1)

VPK only Tu/Th (8-3:30)

NAME/GRADE OF SIBLING(S) ENROLLED AT TCS:

Name/grade of other relative(s) enrolled at TCS:

ADDITIONAL INFORMATION Any unusual factors in child’s life: adoption, accident, or learning disabilities of which the staff should be aware?

We desire to enroll our child at TCS because:

How did you hear about TCS?

Other parents of TCS students

Web site Facebook

Apopka Chief

Other

OTHER FAMILY INFORMATION STEP-FATHER Title: (Mr., Dr., Rev., other ) Name

Address

City State Zip

Home Phone

Cell Phone

Work Phone

AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO

STEP-MOTHER Title: (Mrs., Ms., Dr.,other ) Name

Address

City State Zip

Home Phone

Cell Phone

Work Phone

AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO

PARENT/GUARDIAN ACKNOWLEDGEMENT I understand that the application process is not complete until all required documentation is received, testing is completed, and fees are paid. I understand that the student recommendation form must be received and all academic records including a copy of the current report card and recent achievement test results must be submitted at the time of the entrance exam.

I understand that it is school policy to not make refunds of fees or tuition unless the school is unable to accept my child.

I understand that in submitting this application and signing below I acknowledge it is my responsibility to review the most current Parent/Student Handbook in its entirety and agree to abide by all rules, regulations, and policies of Trinity Christian School. I further understand my child is required to abide by these same policies. (The Parent/Student Handbook is available online and/or for review in the school office.)

I have received a copy of the Child Care Facility pamphlet, KNOW YOUR CHILD CARE FACILITY.

I have received a copy of the Influenza Virus, The Flu, A Guide to Parents.

I have been informed of the disciplinary practices used by the child care facility through the most current Parent/Student Handbook (posted on FACTS Family Portal).

Signature Date

Parent/Legal Guardian

Parent’s/Legal Guardian’s Printed Name

Trinity Christian School Early Childhood and Extended Care’s

Food and Nutrition Policies

Florida Administration Code Chapter 65C-22.006 requires that there be signed statements from the custodial parents or legal guardians that their child care facility has provided them with information on the child care facility’s food and nutrition policies that includes food safety and food allergens. The information for Trinity Christian Early Childhood Department is listed below.

Trinity Christian Early Childhood and Extended Care has adequate equipment available to maintain food safety.

1. Meat, poultry, fish and dairy products and processed foods are inspected under the United States Department of Agriculture requirements.

2. No raw milk or unpasteurized juice is served without the written consent of a parent or legal guardian.

3. No home-canned food is served. 4. No home-grown eggs are served. 5. No recalled food products are served. 6. All raw fruits and vegetables are washed thoroughly before being served or cooked. 7. To prevent food from becoming potentially hazardous, hot foods are maintained at a temperature of

135 degrees Fahrenheit or above, and cold foods are maintained at a temperature of 41 degrees Fahrenheit or below. The facility supplies adequate equipment to maintain temperature requirements.

8. Food is thoroughly cooked and/or reheated.

Parents or legal guardians give written permission in advance of food-related activities, such as special occasions and learning activities, which include food consumption. The permission slips are signed at the time of registration & kept in the individual student file for the current school year.

Parents are made aware of food-related activities as follows (this only applies to ECE, VPK, Extended Care and Summer Camp students):

Regular Meals and Snack: Through monthly menus posted in the Parent Information Board, in the Classroom, in the Dining Room and Online.

Classroom Parties: Through sign-up sheets and parent newsletters Field Trips: Through the Field Trip Calendar (K-High School) Holiday & Summer Breaks) Birthday Parties: Will occur on various dates throughout the school year based on the children’s

birthdates. Learning Activities and Other: Through monthly newsletters provided to parents.

If a special diet is required for a child by the child’s physician, a copy of the physician’s order and a copy of the diet restrictions are kept in the child’s file and followed. The documentation is kept in the child’s file for as long as they are in the care of Trinity Christian School. If the custodial parent or legal guardian notifies Trinity Christian School of any known food allergies, written documentation is maintained in the child’s file for as long as the child is in our care. Staff are notified of special food restrictions and they are posted in a conspicuous location.

Lunch and snack menus are posted on the Parent Information Board located near the Early Education Office and also available online. I have received a copy of the Trinity Christian Early Childhood and Extended Care’s Food and Nutrition policies. I give permission in the form of this general permission slip for my child, ___________________, to participate in food-related activities, including regular meals and snacks, classroom parties, field trips, birthday parties, learning activities and other food-related activities. __________________ ______________________________ ______________________________ _________ Child’s Name Parent Name Parent Signature Date

Trinity Christian School Parental Consent for Use of Photos,

Audio, Digital, or Video Images, Artwork & Written Work Student’s Name: Grade: Throughout the year, photographs, audio, digital, or video images may be taken on and around the TCS campus. Photos and videos may be taken for promotional materials, newsletters, classroom displays, the yearbook, school website, and social media. It is not possible to exclude any student’s image from the yearbook as these may include photos from a variety of sources including those taken of classes and activities. Photos, videos, artwork and/or written work will not be excluded from classroom or campus displays. As you are aware, there are potential dangers associated with the posting of personally identifiable information on a website since worldwide access to the Internet does not allow for control of who may view or access such information. We strive to safeguard your child’s identity while at the same time promoting events and accomplishments. Be aware that we will not release any personally identifiable information (student names, photos or images, addresses, phone numbers, and locations and times of class trips) without prior written consent from you as parent or guardian. As the parent or guardian, you may modify or rescind this agreement at any time by re-submitting this consent form.

I give permission for the above named student’s photo, image, artwork or written work to be published on the school’s print publications, public website, and print media (with first name only when appropriate), and social media (without any names).

Yes No

Name of Parent/Guardian (please print): Signature of Parent/Guardian: Date: Relationship to Student:

Trinity Christian School Parent Statement of Agreement

Student’s Name: Grade:

In submitting an application for my child at Trinity Christian School I acknowledge my agreement with the overall Christian educational program of TCS as expressed in all phases of the curriculum and the instruction of my child. I further understand that my child is required to abide by these same policies. I understand that the teacher and the administration are hereby given full discretion in the discipline of my child in accordance with the discipline policy stated in the most current Parent/Student Handbook as posted in the Family Portal.

Financial (I have read & agree to these policies, please initial. _______) There are no refunds of fees or tuition unless the school is unable to accept my child.

I am responsible for all financial obligations of my child to the school. I understand that printed statements will no longer be mailed. My accurate, active email address has been

provided to receive monthly statements via email. I understand that I may access my account any time on FACTS Family Portal.

I understand that a late fee of $25.00 will be charged for payments not received in the office by 4:00 p.m. on the 5th of the month due. When the 5th of the month falls on Saturday, payment will be due on Friday, the 4th. When the 5th of the month falls on Sunday, payment will be due on Monday, the 6th.

If my account becomes delinquent, my child will be withheld from school until the balance and late fees are paid.

I understand that should a check be returned to the school designating insufficient funds or returned through FACTS PayNow, I must pay any service charges that may be required including a $25.00 returned check charge. After two occurrences of insufficient funds during the calendar year (August-July) either by check or FACTS PayNow, all future payments must be made in cash or with a money order.

I am responsible to pay for lost/damaged books or damage to school property, including computers and other equipment.

I understand that the Book/Activity Fees are billed in two equal installments. The first installment is due June 1. The second installment is due July 1. Late fees will apply to fees not paid by the 5th as stated above.

The full monthly fee is due when a child is enrolled for one or more days of that month. The monthly fee may be prorated for children entering after the 15th of the month.

I understand tuition (K-High School) is an annual charge that is broken down into 10 monthly installments as a convenience, with the first payment beginning August 1. I understand that if my child starts school prior to September 15, I am responsible for the August and September installments of tuition.

Credit will not be given on the following: school tuition, Explorers’ & Adventurers’ class, VPK Wrap Around (5 day 8:00-3:00), VPK 2-day or 3-day programs, Infants – Adventurers 2-day or 3-day options, holidays, sick days, or other campus closures.

Extended Care (I have read & agree to these policies, please initial. _______) Full Time Extended Care is from 6:30 a.m. to 6:00 p.m. All students may arrive in Extended Care after 7:30 a.m. without a charge assessed; however, no student is to arrive in the classroom earlier than 7:50 a.m. No student is to remain on campus unsupervised. Students must be checked into Extended Care or under a teacher’s supervision while on the TCS campus.

I will be present to pick up my child (Infants-High School) after school by 3:20 p.m. (2:20 p.m. Wednesdays/ K-High School only) or other designated time for special event or I will incur additional charges if not enrolled in Extended Care.

I understand that all changes to Extended Care and/or part-day/full-day options must be made in writing on the appropriate form and submitted to the Extended Care office by the 20th of the month prior to use. An administrative change fee of $15.00 will be assessed on changes requested after the 20th of the month prior to the effective date.

Requests for Extended Care will be subject to availability.

Trinity Christian School’s philosophy is to instill the highest standards of academic achievement where there is no mediocrity in Christian education,

but superiority in excellence. To address a glaring void in society that deletes all references to God, creation and divine purpose for the human experience.

To disciple a Christian heart in our students today, and to produce Christian leaders of tomorrow.

Since all children are created in the image of God, Trinity Christian School, a ministry of Trinity Baptist Church, admits students of any race, color,

national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students of the organization. It

does not discriminate on the basis of race, color, national and ethnic origin in administration of hiring policies, educational policies, admissions policies,

scholarship and loan programs, and other organization-administered programs.

Our complete Statement of Faith is found in the Baptist Faith and Message (2000 edition) through Lifeway Church Resources, Nashville, Tn.

I understand that I will be charged a late pick up charge if I do not pick up my child from Extended Care by 6:00 p.m. Late pick up charges are $1.00 per minute per child and paid to the Extended Care worker upon arrival.

All Extended Care HOLIDAYS (days closed) will be posted prior to the holiday. If weather emergencies close Orange or Seminole County schools, TCS and Extended Care will also be closed.

I hereby give permission for my child to attend all extended care field trips. Two weeks of vacation credit is available per child, per calendar year (January – December) for FULL-TIME

Infants, Extended Care, VPK Wrap Around (5-day 6:30-6:00), and Summer Camp. A child must have attended Trinity Christian School and Infants, Extended Care, VPK Wrap Around (5 day 6:30-6:00), and Summer Camp for twelve successive calendar months. Each week of credit must be taken in a 5-day sequence. A vacation notice form must be submitted in advance of the desired vacation dates. Vacation credit is not retroactive. The amount of the vacation credit is determined by the charge for Infants, Extended Care, VPK Wrap Around (5-day 6:30-6:00), or Summer Camp at the time the vacation is taken. Credit will be applied to the account after the vacation has been taken and verified.

New Students (I have read & agree to these policies, please initial. _______) Evaluation of records as well as entrance exam results will be used to determine acceptance to Trinity Christian School.

I understand that the required health form, immunization record, birth certificate and required fees must be submitted prior to acceptance.

I understand that all academic records including a copy of the current report card, recent achievement test results, and the student recommendation form must be received, evaluated and have met the pre-testing assessment criteria before a testing appointment can be scheduled.

I understand that my child will be placed at the grade level and in the class determined by the administration according to test results and other generally accepted educational standards.

Uniforms (I have read & agree to these policies, please initial. _______)

Appropriate dress in elementary and secondary is a designated school uniform. I understand that my child must be appropriately dressed on the first day of school as well as at all other school

functions, as stated in the most current Parent/Student Handbook as posted on FACTS Family Portal.

General (I have read & agree to these policies, please initial. _______) I hereby give permission for my child to participate in all school activities. While the school will make every provision for the safety and care of the students and will see that they are

properly supervised, I will not hold the school liable for any accidents or injuries that may occur at any such activities.

My child agrees to comply with Trinity Christian School entrance requirement forbidding students to use or possess tobacco, alcoholic beverages, weapons (including pocketknives), illegal drugs or medication at school.

My child and I agree to abide by all of Trinity Christian School’s rules, procedures, disciplinary practices, and policies as stated in the most current grade/age appropriate handbook (ECE Handbook, Parent/Student Handbook and/or High School Handbook) as posted in our Family Portal.

I understand that the school reserves the right to dismiss any student who does not respect its spiritual standards or does not cooperate in the educational process or whose parents or guardians fail to cooperate with the school administration.

Early Childhood Education (I have read & agree to these policies, please initial. _______)

I understand that bottles or pacifiers are not allowed in Navigators and sipper cups, pacifiers, bottles and diapers are not allowed in our Explorers thru VPK classes.

I understand my child must be in pull-ups or underwear to attend the Explorers class and completely potty trained to attend the Adventurers & VPK class.

I understand that if my child is three before September 1, but is not potty trained, he or she will not be placed in the Adventurers class.

I understand that my child may only attend the days and hours for which they have been registered. I understand that part-time calendars for Infants – Adventurers part-time students are due by the 15th of the

prior month. I understand my child must not exceed the number of days per week that they are enrolled for (2 or 3 days per

week not 8 or 12 days per month). If they do exceed the numbers of days, a drop-in fee will be assessed.

I have read the Parent/Student Statement of Agreement and agree to abide by the policies. This form is valid for future years, until the student withdraws from Trinity Christian School or is renegotiated by either party. Signature Date Parent/Legal Guardian Parent’s/Legal Guardian’s Printed Name

Trinity Christian School

Medical Authorization and Release Form

Student’s Name DOB / / Grade

Please read CAREFULLY and INITIAL by each item. 1. (___ initial) I hereby give my consent for this child to participate in the School Health Services Program.

This means my child will receive emergency care in school, if needed, and health appraisals at school that may include screenings such as vision, pediculosis, hearing and growth development.

2. (___ initial) In case of an emergency or illness where treatment is not needed, but where my child is

unable to remain at school, I request the school to contact me. If I am unable to be reached, I request that one of the persons listed on the medical information form be contacted to care for my child until I can be reached.

3. (___ initial) In the event of a serious accident or illness, I request the school contact me at the phone

numbers listed on the medical information form. If the school is unable to reach me, I hereby authorize the school to contact the physician or dentist indicated and to follow his/her instructions. If it is impossible to contact the physician or dentist, the school may make whatever arrangements are necessary to provide emergency care and treatment for my child.

4. (___ initial) In the event of a life threatening accident or illness, I understand that the school may contact

911 emergency medical systems immediately. I agree to be financially responsible for my child’s care and treatment.

5. (___ initial) Any student or employee with a communicable disease shall be temporarily excluded from

school while ill and during recognized periods of communicability. 6. (___ initial) All medications, including over the counter emergency medications, do not leave the school

for field trips or after school activities. Parents should make arrangements with the teacher or after school supervisor to provide prescription medication, or over the counter emergency medications, for each field trip or after school activity. All medications must meet standards listed on medical authorization form. Form must be signed by parent before any medication can be dispensed.

7. (___ initial) I further agree to hold the school and its agents harmless for any liability to my child or any

guardian or parent thereof, because of any claims on behalf of my child against the school or agent thereof because of any injury or alleged injury to my child. Should any legal action, for any reason, be taken against Trinity Christian School or any employee or agent thereof on my child’s behalf and the school or its agent not be found at fault, I agree to pay any attorney fees, court fees, damages or other costs that Trinity Christian School or its agent should incur to defend itself against such action.

Permission to Treat/Transport and Release from Liability

The undersigned person, who is the natural parent or legal guardian of the named student, gives consent for the named student to participate in Trinity Christian School/Extended Care field trips, with the clear understanding that participation creates a risk normally associated with such activities. In the event of an emergency, the undersigned person authorizes any representative of Trinity Christian School, in whose care the minor has been entrusted, to present such minor to an approved medical treatment center, and do consent to an X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, to be rendered to the minor under the general practitioner or surgeon licensed to practice in any state of the United States, and do consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care, to be rendered to the minor by a dentist licensed to practice in any state in the United States. I agree to be financially responsible for this child’s treatment. I also request that I be notified of my child’s condition and admission as soon as possible.

In order to expedite care of this child, I hereby give my permission for the responding emergency team to immediately initiate treatment and transport of this child to the preferred or appropriate medical facility, according to what they deem is indicated by the nature or extent of the injuries. I agree to be financially responsible for this child’s treatment and transport. I understand that it is my responsibility to update and maintain current and accurate medical information on RenWeb ParentsWeb. I/WE, as the undersign parent(s) and/or legal guardian(s), realizing the risks involved in the activities my/our child will participate in, hereby unconditionally release and hold harmless Trinity Christian School, Trinity Baptist Church, Inc., its/their employees, agents, officers, directors or members from and against any and all loss, claim, damage, liability or expense, as a result of any negligence by the party(ies) release herein.” Date Parent/Guardian Signature

Trinity Christian School

Medical Information Form Student’s Name DOB / / Grade

Address City Zip

Mother Home Phone

Cell Phone Work Phone

Father Home Phone

Cell Phone Work Phone

List TWO persons to contact if above parents cannot be reached: Name Relationship to child

Home Cell Work

Name Relationship to child

Home Cell Work Medical Information Physician Phone

Dentist Phone

Explain, in detail, any health conditions: (medical conditions, medications and/or history (i.e. previous

surgeries, chronic conditions, etc.)

Medications

Specific allergies Please complete the following by checking the appropriate choice:

Does your child have a history of Asthma? � Yes � No If yes, does your child need an inhaler at school? � Yes � No (please visit clinic for permission form) If yes, where do you want the inhaler kept? (for Elem/Middle School Only) � Backpack � Clinic Does your child have a history of an insect allergy? � Yes � No If yes, what type of insect? � Ant � Bee � Wasp � other If yes, does your child need Benadryl? � Yes � No (please visit clinic for permission form) If yes, does your child need an Epi Pen at school? � Yes* � No

*(MUST BE PROVIDED BY PARENT AND PERMISSION SLIP MUST BE FILLED OUT IN CLINIC) Does your child have a history of a food allergy? � Yes � No If yes, what type of food is your child allergic to? If yes, does your child need Benadryl? � Yes � No (please visit clinic for permission form)

If yes, does your child need an Epi Pen at school? � Yes* � No *(MUST BE PROVIDED BY PARENT AND PERMISSION SLIP MUST BE FILLED OUT IN CLINIC)

Insurance Information:

Company: Policy #: Group #: Insurance preferred hospital (responding medical unit will make final determination as to the appropriate facility for the injury or illness):

Trinity Christian School EMERGENCY CONTACT & PICK-UP AUTHORIZATION

STUDENT(S) GRADE GRADE GRADE PARENT’S SIGNATURE DATE PARENT’S PRINTED NAME

Be sure to include EVERYONE authorized (other than parents) to be contacted in the event of an emergency and those authorized to pick-up the student as this information replaces

previous information on file and will become effective upon registration.

AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO Title Relationship Name Home Phone Cell Phone Work Phone ext. AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO Title Relationship Name Home Phone Cell Phone Work Phone ext. AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO Title Relationship Name Home Phone Cell Phone Work Phone ext. AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO Title Relationship Name Home Phone Cell Phone Work Phone ext.

AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO Title Relationship Name Home Phone Cell Phone Work Phone ext. AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO Title Relationship Name Home Phone Cell Phone Work Phone ext. AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO Title Relationship Name Home Phone Cell Phone Work Phone ext. AUTHORIZED TO PICK-UP YES NO AUTHORIZED EMERGENCY CONTACT YES NO Title Relationship Name Home Phone Cell Phone Work Phone ext.