New Student Medical/Emergency Form

Student Information:

Legal First and Last Name*

First Middle Last Suffix

Nickname or Preferred Name

Birthdate*

MM

DD

YYYY

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Grade Level*

Parent Status

Please describe Parent Status for "Other"

Enrolling Parent/Guardian Information: (Please complete all fields. Enter "NA" if not applicable.)

Relationship to Child:*

Please explain if you selected "Other".

Name*

Prefix First Last Suffix

Is address same as student?*

Yes
No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Mobile Phone*

Home Phone (if different from student)

Employer

Work Title

Work Phone

Is your company a matching gift company?

Yes
No

Is there a second parent?*

Yes
No

Relationship to Child:*

Please explain if you selected "Other".

Name*

Prefix First Last Suffix

Is address same as student?*

Yes
No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Mobile Phone*

Home Phone (if different from student)

Work Title

Employer

Work Title

Is your company a matching gift company?

Yes
No

Work Phone

Is there a third parent?*

Yes
No

Relationship to Child:*

Please explain if you selected "Other".

Name*

Prefix First Last Suffix

Is address same as student?*

Yes
No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Mobile Phone*

Home Phone (if different from student)

Work Title

Is your company a matching gift company?

Yes
No

Work Phone

Is there a fourth parent?*

Yes
No

Relationship to Child:*

Please explain if you selected "Other".

Name*

Prefix First Last Suffix

Is address same as student?*

Yes
No

Email

Mobile Phone*

Home Phone (if different from student)

Work Title

Is your company a matching gift company?

Yes
No

Work Phone

Emergency Contacts: (You must provide two non-parent contacts.)

Emergency Contact Informed*

Yes

I have informed the individuals I have listed as emergency contacts that they are on the "Emergency Contact List" for my child.

Emergency Contact 1 Information

Name*

First Last

Relationship to Student*

Home Phone*

Work Phone

Mobile*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Emergency Contact 2 Information

Name*

First Last

Relationship to Student*

Home Phone*

Work Phone

Mobile*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Medical Information:

Does the student have any allergies requiring an epinephrine?*

Yes
No

If yes above, please complete the Medication Consent Form included in your registration packet and return it to the school with the medication by the first day of school.

Allergy Information:

Please list allergies and any additional information we should know about this condition. (if medication is required during the school day, please complete the Medication Consent Form included in your registration packet and return it with the medication by the first day of school.

Does the student have asthma?*

Yes
No

Does the student require an inhaler?

Yes
No

Please list allergies and any additional information we should know about this condition. (if medication is required during the school day, please complete the Medication Consent Form included in your registration packet and return it with the medication by the first day of school.

Asthma Information

Asthma medication and any additional information we should know about this condition. (if medication is required during the school day, please complete the Medication Consent Form included in your registration packet and return it with the medication by the first day of school)

Does your child have any other medical conditions?

Yes
No

Please list condition/medication and any associated information (if medication is required during the school day, please complete the Medication Consent Form included in your registration packet and return it with the medication by the first day of school).

Medical Authorization*

Yes

In the event of an accident or an illness that does not require immediate treatment, but where my child is unable to remain in school, I understand LCDS will first attempt to contact the Parents/Guardians to arrange transportation for my child. If the Parents/Guardians cannot be reached, I understand LCDS will contact the Emergency Contacts listed above to pick up my child from school. In the event of an emergency, whether on campus or on a school-sponsored trip, I authorize LCDS and its agents to obtain immediate medical care and emergency transportation for my child and to contact the Parents/Guardians immediately. In the event that the Parents/Guardians cannot be contacted, I hereby authorize LCDS to act on my behalf in accordance with their best judgement in any emergency requiring medical attention. I understand LCDS does not provide coverage for illness or injury. I understand that as Parent/Guardian I am fully responsible for the cost of such treatment, services, and transportation. I hereby waive and release LCDS and its agents from any liability due to, or arising out of, the treatment of any illness or injury incurred by my child while at LCDS or any off-campus LCDS activity.

Non-prescription Medications*

I hereby give permission for my child to receive the following non-prescription medication(s), approved by selecting boxes below. I understand that LCDS will administer medication to my child, according to package directions as deemed appropriate. I hereby waive and release LCDS from any liability for damages as a result of an adverse reaction or any other injury suffered by my child due to administration of these non-prescription medications.
I do not give permission for my child to receive non-prescription medication(s).

Tums

Yes, I approve administration of calcium carbonate or generic Tums.
No, I do not approve administration of calcium carbonate or generic Tums.

Tylenol (or generic)

Yes, I approve administration of acetaminophen or generic Tylenol
No, I do not approve administration of acetaminophen or generic Tylenol

Advil (or generic)

Yes, I approve administration of ibuprofen or generic Advil
No, I do not approve administration of ibuprofen or generic Advil

Prescription and/or Over-the-Counter Medication*

I will provide the following prescription and/or over-the-counter medication(s) to LCDS along with a corresponding Medication Consent Form for each medication. I confirm that my child has previously taken all of the prescription and/or over-the-counter medications listed below with the exception of epinephrine. I understand that all medication brought to LCDS must be in the original container and packaging properly labeled with the child's first and last name, dosage (time and amount) clearly marked, and include a fully completed Medication Consent Form, and must be checked in to the Main Office. I hereby waive and release LCDS from any liability for damages as a result of an adverse reaction of any other injury suffered by my child due to administration of these prescription and/or over-the-counter medications.
I will not be providing any prescriptions to LCDS.

List Medication Names Here*

Emergency Medical Authorization

Student's Physician*

Physician Phone Number*

Insurance Provider*

Employer through which coverage is provided.*

Insurance Policy Number*

Pickup Authorization

Pick Up Authorization

Full Name	Contact number	Contact number	Relationship to Child

The following person(s) are authorized to pick up my child. I will send an email or call LCDS on days when they will be picking up.

Releases:

Media Release: Students are periodically photographed and/or videotaped while participating in various activities during the school year. Frequently this media is shared internally through password-protected outlets to the LCDS Community. There are occasions where media is used in publications and outlets that are public. In these instances, your permission to use photos/media of your child is required. Please respond below your preferences regarding publically-shared media outlets.

External Publications Release*

Yes
No

Does LCDS have your permission to use photos of your child in external publications (such as the Annual Report, ads, press releases, brochures, etc.)?

Group Photos

Yes
No

If you answered "no" above, does LCDS have your permission to use group photos that include your child without identifying names in external publications?

Special Approval

Yes
No

If you answered "no" above, would you like the opportunity for LCDS to contact you for approval to use photos of your child in external publications for select situations?

Website Release*

Yes
No

Does LCDS have your permission to use photos and media of your child on the school website?

Group Photos

Yes
No

If you answered "no" above, does LCDS have your permission to use group photos that include your child without identifying names on the LCDS website?

Special Approval

Yes
No

If you answered "no" above, would you like the opportunity for LCDS to contact you for approval to use photos of your child on the LCDS website for select situations?

Social Media Release*

Yes
No

Does LCDS have your permission to use photos of your child on “official” LCDS social media outlets (such as Facebook)?

Group Photos

Yes
No

If you answered "no" above, does LCDS have your permission to use group photos that include your child without identifying names on official LCDS social media?

Special Approval

Yes
No

If you answered "no" above, would you like the opportunity for LCDS to contact you for approval to use photos of your child on official LCDS social media?

Technology Releases:

Responsible Use Agreement*

Yes

My child and I have read, consent, and agree with the LCDS Responsible Use Agreement for Students.

COPPA Statement*

Yes

I have read, consent, and agree with the LCDS COPPA Statement.

Field Trip Permission:

Field Trip Participation*

Yes
No

Does your child have permission to participate in ALL field trips sponsored by Loudoun Country Day School unless otherwise notified?

Field Trip Private Vehicle Transportation*

Yes
No

Does your child have permission to ride in private vehicle for field trips sponsored by Loudoun Country Day School?

Other Information:

Grandparents: Grandparent's Day is a special tradition during the spring at LCDS. Invitations to attend will be sent to all grandparents. Please provide names and full addresses to be used for invitations and newsletters.

Grandparent 1

Prefix First Last Suffix

Grandparent 1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Grandparent 2

Prefix First Last Suffix

Grandparent 2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Grandparent 3

Prefix First Last

Grandparent 3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Grandparent 4

Prefix First Last Suffix

Grandparent 4 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Extended Family

Full Name	Address	Relationship to Child

LCDS will send newsletters and invitations to special events to extended family members of your choosing. Please list their full names and addresses below, including relationship to your child, to be used for invitations.

Does the students have siblings who do not attend LCDS?*

Yes
No

Please list sibling(s) Name and Date(s) of Birth

Full Name	Date of Birth

Affirmation*

Yes, I affirm.

I affirm that entering my home phone number and submitting this form constitutes an electronic signature of this form.

Name of Person Completing this Form*

Home Phone*

New Student Medical Information and Emergency Form