Summer Camp 2024 Health/Emergency Form Step 1 of 4 - Student Information 0% Student InformationName* First Last Birthdate* Month Day Year Grade in September 2024*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeGender* Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Lives With* Both Parents Mother Father Other Student Background*In order to help us better meet your child's needs, please answer each of the following questions:YesNoHas this child ever repeated a grade?Has this child ever been dismissed, suspended, or expelled?Has this child ever been recommended for, or referred to, any Resource, ESL, or Special Education?Has this child ever been diagnosed with any behavioral concerns (e.g., ADD, ADHD)?Does this child have any physical limitations or handicaps?Please briefly explain any "Yes" answersName of Child's Doctor:* Physician's Phone #Insurance: Insurance ID #: Student Health*Please indicate the illnesses and diseases your child has or has had in the past:YesNoAllergyAsthmaDiabetesEpilepsy/SeizuresFainting SpellsVision ProblemHearing ProblemHeart ConditionMigraine HeadachesAllergies (specify type) Medications (specify any taken) Significant Medical Problems Mother/Guardian* First Last Home Address* Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Enter Email Confirm Email Mobile Phone*Home PhoneWork PhoneFather/Guardian First Last Home Address Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Enter Email Confirm Email Mobile PhoneHome PhoneWork PhoneCustody AgreementsCustody*Do you have any current custody agreements we should be aware of? Yes No Description*Please briefly describe the agreement. Any restrictions must be accompanied by a copy of the current court order.Current Court OrderPlease upload a copy of the current court order.Max. file size: 32 MB. In the event that I am unable to pick up my child, he or she may be released to any of the persons listed below:Name* First Last Relationship to Child* Contact Information Same as previous Street Address City ZIP Code Mobile Phone*Other PhoneName* First Last Relationship to Child* Contact Information Same as previous Street Address City ZIP Code Mobile Phone*Other PhoneName First Last Relationship to Child Contact Information Same as previous Street Address City ZIP Code Mobile PhoneOther Phone Authorization AgreementPlease read through the Admission Agreement and check the box below. Please note: Jubilee Christian School is known hereafter as "JCS." JCS reserves the right to change or modify academic, administrative, and financial policies as necessary, while recognizing its obligation to give parents adequate notice of any changes.Medical Authorization*In the event of illness or injury, I do hereby authorize and consent to any x-ray, examination, anesthetic, medical, surgical, or dental diagnosis and/or treatment and hospital care are considered necessary in the reasonable judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing such medical or dental services. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required and is given to provide authority and power to render any care which the medical provider may reasonably deem advisable. I further agree not to hold liable Jubilee Christian School, its officers, employees, board members, or agents for any such medical or health care services provided and to reimburse Jubilee Christian School for such medical or other health care expenses incurred in the child’s care. This authorization is provided pursuant to Section 25.8 of the Civil Code of California. I have read, understand, and agree to the above Parent/Legal Guardian Signature* Reset signature Signature locked. Reset to sign again Application ReviewPlease take a moment to review your Health/Emergency Form in full.{all_fields}CommentsThis field is for validation purposes and should be left unchanged.
