2018-2019 R.G Drage Emergency Medical Authorization
Purpose - To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached. This information may be shared with the educational team to best meet your child's needs.
Student First Name *
Your answer
Student Last Name *
Your answer
Address *
Your answer
Address Change *
Birthdate *
MM
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Preferred Phone Number *
Your answer
Bus #
Your answer
School District *
Your answer
School Attending *
Your answer
Grade- Please enter grade number. *
Your answer
Homeroom
Your answer
Sex *
Residential Parent or Guardian:
Mother First Name
Your answer
Mother Last Name
Your answer
Mother Day Phone #
Your answer
Mother Cell Phone #
Your answer
Mother Email Address
Your answer
Father First Name
Your answer
Father Last Name
Your answer
Father Day Phone #
Your answer
Father Cell Phone #
Your answer
Father Email Address
Your answer
1. Other Contact First Name
Your answer
1. Other Contact Last Name
Your answer
1. Relationship
Your answer
1. Day Phone #
Your answer
1. Cell Phone #
Your answer
2. Other Contact First Name
Your answer
2. Other Contact Last Name
Your answer
2. Relationship
Your answer
2. Day Phone #
Your answer
2. Cell Phone #
Your answer
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor Name *
Your answer
Doctor Phone # *
Your answer
Dentist Name *
Your answer
Dentist Phone # *
Your answer
Medical Specialist Name
Your answer
Medical Specialist Phone #
Your answer
Hospital Name *
Your answer
Hospital Phone # *
Your answer
Check below any current health conditions that may require attention during the school day:
Allergies - Food- Please be specific
Your answer
EpiPen for Food
Allergies - Medicine- Please be specific
Your answer
Allergies - Bee Sting
EpiPen for Bee Sting
Other Allergies
Your answer
Asthma *
Asthma- Use emergency inhaler
Asthma- Inhaler will be at School
Cancer *
Diabetes *
Seizures *
Heart Problems *
If heart problems please be specific below
Your answer
Physical Disability *
If Physical Disability please be specific below
Your answer
List all medications and dosages your child receives on a continual basis:
Your answer
Other health conditions- please be specific
Your answer
Previous Surgeries- Include Date
Your answer
Previous concussions/ head injury- Include year
Your answer
Hearing Problems
Has hearing aids
Vision Problems
Wears
ADHD
Behavior or Emotional Problems
Behavior or Emotional Problems- Please Explain
Your answer
Bleeding Disorder *
PLEASE COMPLETE PART I or PART II NOT BOTH
Part I — TO GRANT CONSENT In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for: (1) the administration of any treatment deemed necessary by the designated physician or dentists, or in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to the designated hospital or any hospital reasonably accessible.This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Date- PART 1
MM
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Parent or Guardian Signature- PART 1
By placing your name and submitting the form you are agreeing to the terms.
Your answer
PART II- I do not give my consent for emergency medical treatment of my child.
In the event of illness or injury requiring emergency treatment, I wish the school authorities to take no action or to:
Your answer
Date- PART II
MM
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Parent or Guardian Signature- PART II
By placing your name and submitting the form you are agreeing to the terms.
Your answer
Parent/Student Email *
Cooperation and Communication among students, teachers and parents will ensure a more profitable learning experience for students. The R.G. Drage Career Center requests your permission to communicate with you via email regarding the educational progress of your son or daughter. Such communication may not be limited to but include his or her grades.
Please list your email address below
Your answer
Student Media Release Form *
The R.G. Drage Career Technical Center request your permission to include your child's name or picture in media releases, along with information about school activities in which he/she is engaged. This information may be used in such publications as building newsletters or our schools' website on the internet. No personal information such as student phone numbers or addresses will be released. If you have any questions, please feel free to call our office 330-832-9856 or 1-800-372-4322. By submitting this form you are agreeing to the terms below.
Legal Consent for Emergency Treatment *
I being the parent/legal guardian give my consent for emergency treatment for my son/daughter, in the event that all reasonable attempts to reach me at the numbers provided above on the emergency medical authorization form are unsuccessful. This consent allows the school to call an ambulance, at my expense, if I cannot be reached or cannot provide transportation for further medical attention. I also give consent to the school nurse to give first aid to my son/daughter, if necessary.
Required
Non-Prescription Medication Authorization
Students wishing to take non-prescription medication MUST BRING THE MEDICATION TO SCHOOL IN THE UNOPENED CONTAINER IN WHICH IT WAS PURCHASED and have the form completed and signed by a parent/guardian. Please check the medication below which your child may take during the school day and submit this form. By submitting the form you are agreeing to the terms. Dosage per box instructions will be followed unless otherwise indicated. The nurse is not permitted to give more dosage than dosage recommended on the box. I GIVE DESIGNATED SCHOOL PERSONNEL PERMISSION TO ADMINISTER THE FOLLOWING NON-PRESCRIPTION MEDICATIONS DURING SCHOOL HOURS IF NEEDED:
Technology Agreement- Acceptable Use of Technology Agreement Including Internet Use & Safety
Students and residential parents or guardians shall agree and acknowledge the information disclosed in this agreement by signing below. This agreement is in effect until the student leaves the District or a new agreement is required. For students 18 years and older, the student agrees that they understand and agree to abide this agreement. For all other students, the parent agrees that they have explained this agreement to their child and that the child agrees to abide by the agreement.By placing your name and submitting this form you are agreeing to the Acceptable Use of Technology Agreement Including Internet Use & Safety
Tech Agreement- Parent Name *
Your answer
Tech Agreement- Student Name *
Your answer
School Insurance *
It is the responsibility of each student and/ or the parent or guardian to have accident insurance coverage that complies with one of the following: (check one):
Required
School Insurance Waiver- Signature
I am the legal guardian of the student who I am completing this information for. I have chosen not to obtain general liability insurance coverage for him/her through a private insurance company or through my child's home school. Therefore I hereby waive any cause of action against R.G. Drage Career Technical Center and/or it's employee and/or their insurers on behalf of my child and his/her parent in the event of injury to my child which would have been ordinarily covered under the terms of standard general liability insurance policy. By placing your name below and submitting this form you are agreeing to the terms of the school insurance waiver.
Your answer
Student Handbook
By placing your name and submitting this form you are agreeing to the terms of the student handbook.

Please click the link below to access the Student Handbook

https://drive.google.com/file/d/1ZNtiupT0olt1kNA-CoQ4JCJ5C-DeWpi9/view?usp=sharing

Student Handbook- Parent Name *
Your answer
Student Handbook Student Name *
Your answer
Career Tech Program *
Required
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