Deubrook JH-SH 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.
Your answer
Parent/Guardian Last Name *
Your answer
Parent/Guardian First Name *
Your answer
Student Last Name *
Your answer
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).
Your answer
Grade(s) of Student *
If you have more than one grade 7-12 student, select all that apply.
Required
Acceptable Use Policy *
Please read and review the following link pertaining to the Deubrook Area School District's Acceptable Use Policy: https://drive.google.com/open?id=1qdu-H5u1NKn4aNBZKIQz6iMAnNuh5c5-
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.
Required
Emergency Contact Information *
If parents cannot be located in an emergency, who should be contacted? Please list name, phone number, address and relationship to student(s).
Your answer
Emergency Medical Information *
If parents cannot be located in an emergency, please list your doctor's and dentist's names and phone numbers.
Your answer
Permission Form *
Do you grant permission for your child(ren) for the following:
Captionless Image
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.)
Required
Acknowledgment of Review of Student Handbook *
Please read the contents of the student handbook. The direct link to the handbook is https://drive.google.com/open?id=1IFG6KdNNI3jm_S7rjddZ5U3uBZphWm3t If you would like a hard copy, please contact linda.ray@k12.sd.us 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.
Co-Curricular - Parent or Guardian Permission *
I give my permission for my son/daughter to participate in organized athletics, realizing that such activity involves the potential for injury that is inherent in all sports.
Co-Curricular - Parent Consent for Medical Treatment *
I am the mother/father/legal guardian for the child listed on this form (or children listed on this electronic form) who participates in co-curricular activities for Deubrook Area Schools. I hereby consent to any medical services that may be required while said child is under the direct supervision of an employee of the Deubrook Area School District while on a school-sponsored activity and hereby appoint said employee to act on behalf in securing necessary medical services from any duly licensed medical provider.
Co-Curricular - Child Consent for Medical Treatment
I, enter name below (e.g. child enters name below, if more than one child -each child's name needs to be entered), have read the above Parent Consent for Medical Treatment section that has been signed by my parent/guardian and join with him/her in the consent. If your child does not participate in co-curricular activities, please leave this question blank.
Your answer
Consent for Release of Medical Information (HIPPA) *
Form to be completed annually and must be available for inspection at the school. 1. I authorize the use or disclosure of the above named individual’s health information including the Initial and Interim Pre-Participation History and Physical Exam information pertaining to a student’s ability to participate in South Dakota High School Activities Association sponsored activities. A Health Care Provider generating or maintaining such information may make such disclosure. 2. The information identified above may be used by or disclosed to the athletic trainer, coaches, medical providers and other school personnel involved in the care of this student. 3. This information for which I am authorizing disclosure will be used for the purpose of determining the student’s eligibility to participate in extracurricular activities, any limitations on such participation and any treatment needs of the student. 4. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school administration. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. 5. This authorization will expire on July 1, 2020. 6. I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 7. I understand authorizing the use or disclosure of the information identified above is voluntary. However, a student’s eligibility to participate in extracurricular activities depends on such authorization. I need not sign this form to ensure healthcare treatment.
Concussion Fact Sheet For Parents *
Concussion Fact Sheet For Athletes *
SDHSAA Annual Parent and Student Consent Form *
Notification of Information "No Child Left Behind Act"
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