New Student Medical Information and Emergency Form

1Student Information

2Parent Information

3Emergency Contacts

4Medical Information

5Releases & Permissions

6Additional Information

7Affirmation

Full Legal Name *

First

Middle

Last

Nickname or Preferred Name

Birthdate *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Grade Level *

Race/ethnicity *

Is the student of Hispanic or Latino origin? *

Yes
No
Prefer not to answer

Parent Status *

Parent/Guardian Information

Please complete all fields. Enter "N/A" if not applicable.

Relationship to Child *

Name *

First

Last

Is address same as student? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Mobile Phone *

Home Phone (if different from student)

Work Phone

Employer

Work Title

Is your company a matching gift company?

Is there a second parent/guardian? *

Relationship to Child *

Name *

First

Last

Is address same as student? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Mobile Phone *

Home Phone (if different from student)

Work Phone

Employer

Work Title

Is your company a matching gift company?

Is there a third parent/guardian? *

Relationship to Child *

Name *

First

Last

Is address same as student? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Mobile Phone *

Home Phone (if different from student)

Work Phone

Employer

Work Title

Is your company a matching gift company?

Is there a fourth parent/guardian? *

Name *

First

Last

Relationship to Child *

Is address same as student? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Mobile Phone *

Home Phone (if different from student)

Work Phone

Employer

Work Title

Is your company a matching gift company?

Emergency Contacts (two non-parent contacts must be provided)

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 Name *

First

Last

Relationship to student *

Mobile Phone *

Home Phone (if different from mobile)

Work Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact 2 Name *

First

Last

Relationship to Student *

Mobile Phone *

Home Phone (if different from mobile)

Work Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pick Up Authorization

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.

Authorized pick-up 1

First

Middle

Last

Authorized pick-up 2

First

Middle

Last

Authorized pick-up 3

First

Middle

Last

Authorized pick-up 4

First

Middle

Last

Medical Information

Does the student have any allergies that require the prescription of an epinephrine autoinjector? *

Allergy information *

I understand that if medication is required during the school day, I will need to complete and submit a separate Medication Consent Form. (The form can be found on the "Parent Forms and Information" page of the parent portal under "Additional Medical Forms and Information") *

Yes, I understand

Does the student have asthma? *

Does the student require an inhaler? *

Asthma information (please list allergies and any additional information we should know about this condition) *

Yes, I understand

Does your child have any other medical conditions? *

Please list condition/medication and any associated information. *

Yes, I understand

Medical Authorization *

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 that LCDS will first attempt to contact the Parents/Guardians to arrange transportation for my child. If the Parents/Guardians cannot be reached, I understand that 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 that 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.

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. *

Acetaminophen (Tylenol)
Ibuprofen (Advil)
Calcium Carbonate (Tums)
I do not approve the administration of any non-prescription medications

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 with packaging properly labeled with the child's first and last name, dosage (time and amount) clearly marked, 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 or any other injury suffered by my child due to the administration of these prescription and/or over the counter medications.
I will not be providing any prescription or over the counter medications to LCDS

List Medication Names Here *

Student's Physician *

Physician Phone Number *

Insurance Policy Number *

Media Releases

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

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

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

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?

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

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

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?

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

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

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 outlets for select situations?

Technology Releases

Please check the boxes below to verify that you have read our technology policies *

My child and I have read, consent to, and agree with the LCDS Student Computer Policy & Responsible Use Agreement.
I have read, consent to, and agree with the LCDS COPPA Statement.

Field Trip Permission

Does your child have permission to participate in ALL field trips sponsored by LCDS unless otherwise notified? *

Does your child have permission to ride in private vehicles for field trips sponsored by LCDS? *

Additional 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
First
Last

Grandparent 1 Address
Address Line 1
Address Line 2
City
State
Zip Code

Grandparent 2
First
Last

Grandparent 2 Address
Address Line 1
Address Line 2
City
State
Zip Code

Grandparent 3
First
Last

Grandparent 3 Address
Address Line 1
Address Line 2
City
State
Zip Code

Grandparent 4
First
Last

Grandparent 4 Address
Address Line 1
Address Line 2
City
State
Zip Code

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

Name and Address
First
Middle
Last

Name
First
Middle
Last

Does the student have siblings who do not attend LCDS? *
Yes
No

Please list sibling(s) name(s) and date(s) of birth
First
Last

Sibling name and date of birth
First
Last

I affirm that entering my contact information and submitting this form constitutes an electronic signature. *
Yes, I affirm.

Full name of person completing this form *

Primary phone *

Email *

New Student Medical Information and Emergency Form

Parent/Guardian Information

Emergency Contacts (two non-parent contacts must be provided)

Pick Up Authorization

Medical Information

Media Releases

Technology Releases

Field Trip Permission

Additional Information

Parent Links