Ravinia Real Kids Forms - Winter/Spring 2019
Emergency Form
New emergency forms are required for each student per session.
Child's Last Name: *
Your answer
Child's First Name: *
Your answer
Teacher:
Your answer
Grade: *
Home Address: *
Your answer
Parent/Guardian Name (Primary Contact): *
Your answer
Parent/Guardian Home Phone (Primary Contact):
Your answer
Parent/Guardian Work Phone (Primary Contact):
Your answer
Parent/Guardian Cell Phone (Primary Contact): *
Your answer
Parent/Guardian Email (Primary Contact): *
Your answer
Parent/Guardian Name (Secondary Contact):
Your answer
Parent/Guardian Home Phone (Secondary Contact):
Your answer
Parent/Guardian Work Phone (Secondary Contact):
Your answer
Parent/Guardian Cell Phone (Secondary Contact):
Your answer
Parent/Guardian Email (Secondary Contact):
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Relationship: *
Your answer
Emergency Contact Home Phone:
Your answer
Emergency Contact Work Phone:
Your answer
Emergency Contact Cell Phone: *
Your answer
Family Doctor Name: *
Your answer
Family Doctor Phone Number: *
Your answer
Family Dentist Name: *
Your answer
Family Dentist Phone Number: *
Your answer
SPECIAL INSTRUCTIONS
***PLEASE LIST ALL ALLERGIES, MEDICATIONS, SEIZURE DISORDERS, SOCIAL, EMOTIONAL, BEHAVIORAL OR LEARNING ISSUES AND ANY OTHER PERTINENT MEDICAL INFORMATION: *
Your answer
In case of emergency, I give Real Kids supervisors or staff permission to call the doctors named above and/or the Highland Park Emergency Services. I give such individuals permission to take the necessary emergency measures. I agree to assume all responsibility and expense incurred at this time. By selecting "I Agree" I am providing my consent as an electronic signature. *
Required
Date Signed:
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North Shore School District 112 Extracurricular Parental Permission and Waiver of Liability
New forms are required for each student per session.
Program Description:
Ravinia Real Kids After School Enrichment Program - Winter/Spring 2019 Session (1/14/19 - 5/16/19)

NSSD 112 affords every student with opportunities to explore personal interests and talents. We believe that every student can find success and pleasure in one or several before or after school activities. Participation in intramural sports, as well as any extracurricular activity or club, especially transportation to an away activity involves an inherent risk of injury. However, the Board of Education of the School District cannot assume responsibility for the safety and welfare of students while they are on or off campus beyond making reasonable provision for their supervision by representatives of the School District designated to supervise the activity.

Students requiring emergency medication, such as, but not limited to, Epi-pens, asthma inhalers or supplies for diabetes care, are encouraged to self-carry their medication. If your child is unable to self-carry his/her emergency medication, it is requested that the parent/guardian provide a second set to the coach or activity sponsor. Please note: The second set will be returned to the parent/guardian after the activity is finished. Please contact your school nurse for appropriate self-carry medication authorization forms and/or medication authorization forms. All medication authorization forms must be completed and returned in order to participate in the activity. Accommodations for all children needing emergency medication must be arranged with the activity sponsor or coach. Please indicate on the bottom of this form if emergency medication is necessary.

I hereby authorize the staff of NSSD 112 to act for me according to their best judgment in any emergency requiring medical attention and I hereby authorize NSSD 112 and its employees and agents, in my behalf and stead, to administer or to attempt to administer medical aid when necessary for any injury or illness incurred while participating in a school sponsored activity and/or during the transportation to and from a school sponsored activity. I authorize treatment of my child by a qualified physician or nurse in the event he/she should require medical attention. I acknowledge that it may be necessary for the administration of first aid and/or emergency medications to my child to be performed by an individual other than the school nurse, and specifically consent to such practices. As a guardian of a student in NSSD 112, I agree to hold harmless and indemnify the District, its employees and agents, either jointly or severally, except for willful and wanton conduct, from and against any and all claims, damages, causes of action, injuries, costs and expenses, including attorney’s fees, incurred or resulting from the administration or attempt at administration of medical aid or the arrangement for emergency medical assistance and treatment. *
Required
I have read and fully understand that as the Parent/Guardian of this student, I accept general liability for the participation of my child in an extracurricular activity and waive and release all claims. All emergency medication requirements necessary for my child are listed on this form. I understand that all medication authorization forms need to be completed and on file with the school nurse. *
Required
***Emergency Medication Required? *
If emergency medication is required, please indicate what it is:
Your answer
I consent to the terms of this permission form and waiver of liability. By selecting "I Agree" I am providing an electronic signature indicating my consent. *
Required
I consent to the terms of this permission form and waiver of liability. By selecting "I Agree" I am providing an electronic signature indicating my consent. *
Required
Date waiver electronically signed: *
MM
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DD
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YYYY
Student Name: *
Your answer
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