Release & responsibility forms


Child's Name
Child's Name
Medical Release
In the event that neither parent can be reached, please list additional emergency contacts below in the order that contact should be attempted. Authorized persons will have to submit a copy of their driver’s license as proof of identification for initial pick up.
Contact #1
Contact #1
Phone
Phone
Contact #2
Contact #2
Phone
Phone
Medical History & Provider Information
I hereby authorize and give permission for City Schoolhouse to seek emergency medical treatment for my child in the event they are unable to reach myself or any other parent, guardian or emergency contact of my child. In furtherance of any treatment decisions to be made for the benefit of my child, I authorize City Schoolhouse to request, obtain, review and inspect any and all information bearing upon my child’s health and relevant to any such decisions to be made respecting such treatment. I also agree that I will be responsible for any financial debt incurred by City Schoolhouse in furtherance of the aforesaid actions. Should the need arise, the following emergency treatment procedure will be followed: • A trained or certified staff member will take whatever immediate steps necessary to stabilize the child’s condition. • If further care is needed, appropriate medical personnel will be contacted (i.e. 911). • The child’s parent or guardian will be notified of the situation as soon as possible. I have read and understand the above outlined emergency care procedures.
Parent/Guardian
Parent/Guardian
Date
Date
Pediatrician
Pediatrician
Pediatrician's phone number:
Pediatrician's phone number:
Media Release
I give my consent for my child’s photograph to be used in printed materials, videos, or any promotion of City Schoolhouse. I give the school permission to publish any work my child produces for the purpose of using it as an example of what City Schoolhouse is accomplishing with its students. Filling out this form will act as a signature of approval.
Child's Name
Child's Name
Parent/Guardian's Name
Parent/Guardian's Name
Dismiss Release
I authorize the following people to pick up my child from school. Authorized persons will have to submit a copy of their driver’s license as proof of identification for initial pick up.
Contact #1
Contact #1
Phone
Phone
Contact #2
Contact #2
Phone
Phone
Financial & Scholarly Responsibility
Financial Responsibility Pledge I agree to meet the tuition requirements with some combination of cash and volunteerism. Our family commits to the previously specified amount per month in cash. I understand that if I do not meet the tuition requirements, my child’s registration may be cancelled. Scholarly Partnership Pledge I agree to participate in my child’s education by discussing topics covered in class at home with my child throughout the week, and on days when we do not meet for class. I agree to ensure that my child is on time to school and any other required events such as volunteer activities and or field trips. I agree to make sure that my child comes dressed appropriately for our learning environment.
Pledge
I hereby agree to the above stated Financial Responsibility Pledge & the Scholarly Partnership Pledge. I understand that the submission of my name below is as binding as a signature.
Parent/Guardin Name
Parent/Guardin Name
Date
Date