Deubrook Elementary PS-6 School Registration Forms
Name of Parent/Guardian Completing Form
By entering your full name below, you are indicating that you are the person you say you are and this electronic signature indicates you are providing permission, consent, and/or information for the questions that follow.
Parent/Guardian Last Name
Parent/Guardian First Name
Student Last Name
Student(s) First Name
If you have more than one student, enter all first names in the space below (please separate names with a comma and start with your oldest child).
Grade(s) of Student
If you have more than one elementary student, please select all that apply.
Acceptable Use Policy
Please read and review the following link pertaining to the Deubrook Area School District's Acceptable Use Policy:
We accept the conditions of Deubrook Area Schools District 5-6 Acceptable Use Policy and plan to access the district’s system/network.
We do not accept the conditions of the Deubrook Area Schools District 5-6 Acceptable Use Policy and will not access the district’s system/network.
NAME Permission for Deubrook Web Pages
Do you give permission for your child(ren)’s NAME to appear on school web pages?
PHOTO Permission for Deubrook Web Pages
Do you give permission for your child(ren)’s PHOTO to appear on school web pages?
Student Health Conditions
Please identify any health conditions your child has that may at some time pose a problem for him/her in the classroom or at school-related activities (examples—asthma, epilepsy, diabetes, allergies, etc.). If YES, check other and list child's name and health condition.
No, my child does not have any health conditions.
Emergency Contact Information
If parents cannot be located in an emergency, who should be contacted? Please list name, phone number and relationship to student(s).
Emergency Medical Information
If parents cannot be located in an emergency, please list your doctor's and dentist's names and phone numbers.
Do you grant permission for your child(ren) for the following:
Over-the-counter Medication Permission
If my child is ill, he/she has permission to receive the following: Please check all that apply. (It will be given as directed on the bottle.)
Equate brand Jr. Strength acetaminophen 160 mg. chewable
Equate brand acetaminophen 325 mg.
Equate brand Ibuprofen 200 mg.
Equate Antacid tablet 750 mg.
No, my child does not have permission for medication.
Physical Education Form
Please read and review the following letter:
I have received your letter and am returning the following information for the classification of this student in the Deubrook Elementary Physical Education program. I have filled out this form fully and completely and have listed all crippling diseases such as broken bones, polio, epilepsy, asthma, diabetes, hemophilia, etc. as well as other medical issues or history the physical education teacher should be aware of. Please select one of the following options:
My child may participate fully in physical education class.
My child is not allowed to participate in physical education class.
My child is limited in physical education class. Please choose other. Be specific and describe the limitations below:*
Acknowledgment of Review of Student Handbook
Please read the contents of the student handbook. The direct link to the handbook is
If you would like a hard copy, please contact
If you have any concerns or questions, please contact the principal. Each student/learner and parent is expected to review and understand the contents of applicable student handbooks.
We (student and parent) have reviewed a copy of the handbook and understand student responsibilities, rules, and regulations set forth in the student handbook.
Never submit passwords through Google Forms.
This form was created inside of State of South Dakota K-12 Data Center.
Terms of Service