Student Visits & Shadows | The First Academy

Student Information

Date you wish student to shadow*

Student's Current Grade*

Student's First Name*

Middle

Last Name*

Date of Birth*

Current School*

Who invited you to Shadow for the day?*

Upload a Recent Picture of Student:

Accepted file types: jpg, gif, pdf, tif, png, , Max. file size: 7 MB.

Parent/Guardian Information

Parent/Guardian's First Name (1)*

Middle

Last Name*

Parent/Guardian's First Name (2)

Middle

Last Name

Parent's Cell*

Parent's Email*

Are you interested in enrolling your student for the CURRENT school year?*

Yes
No

Student's Interest

Is your student interested in sports? If yes, which ones?*

Student's Favorite Activities

Other Comments

Physician Information

Physician

Physician's Phone

Physician's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Dentist Information

Dentist

Dentist's Phone

Dentist's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insurance Information

Insurance Company

Insurance Policy Number

Group

Insurance Preferred Hospital

(Responding medical unit will make final determination as to the appropriate facility for the injury.)

Medical Conditions*

Explain, in detail, any health considerations that may affect this child while at school (i.e., chronic conditions, previous surgeries, none, etc).

Prescription Medications (None? Please indicate so)*

Please note: School based emergency medications do not leave the school for field trips or after school activities. The parents have the responsibility of making arrangements with his/her child's teacher or after school personnel supervising your child in providing emergency medication, from home, for each field trip or after school activity.

Does this student have a history of Asthma?*

Yes
No

If yes, will an inhaler be needed at school?*

Yes
No

You answered 'Yes' to your student needing an inhaler at school. Please provide the school's clinic with a signed consent form.

The inhaler will be kept in*

Allergies (None? Please indicate so)*

(Please detail any important allergies including insect bites/stings, foods, etc.)

Does your child have an Ephinephrine Injection?*

Yes
No

Will students be bringing an Epi-pen?

Yes, he will be sent with an Epi-pen.
No my child will not be sent with an Epi-pen.

You indicated your student has an Ephinephrine Injection, you must provide the school's clinic with a signed consent form from the lower school clinic.

Student Health Service Consent

Participate in the School Health Services Program?*

Yes
No

Consent given for my student to participate in the School Health Services Program. This means my student will receive emergency care in school, if needed, and health appraisals at school, including screenings such as vision, pediculosis, scoliosis, and hearing and growth development. I will notify the school of any changes of this information in writing and submit it to the clinic personnel.

Request Contact?*

Yes
No

Consent given in case of an accident or illness where treatment is not needed, but where my student is unable to remain at school, I request the school contact me. If I am unable to be reached, I request that one of the emergency contact persons listed in my Ren-Web Family Profile be contacted to care for my student until I can be reached. I will notify the school of any change of this information in writing and submit it to the clinic personnel.*

Contact via Ren Web?*

Yes
No

In the event of a serious accident or illness, I request the school contact me at the numbers listed in my Ren-Web Family Profile. If the school is unable to reach me, I hereby authorize the school (noted by my initials) to contact the physician or dentist indicated and to follow his/her instructions. If it is impossible to contact the physician or dentist or if no physician or dentist's name has been provided above, the school may make whatever arrangements are necessary to provide emergency care and treatment for my student. I will notify the school of any changes in writing and submit it to the clinic personnel.

Contact 911?*

Yes
No

In the event of a life threatening accident or illness, I understand that the school may contact the 911 emergency medical systems immediately. My selection indicates my agreement to be financially responsible for my student's care and treatment.

Immediate Treatment?*

Yes
No

In order to expedite care of my student, my selection hereby give my permission for the responding emergency team to immediately initiate treatment and transport of my student to the preferred or appropriate medical facility, according to what they deem is indicated by the nature or extent of the injuries. I agree to be financially responsible for my student's treatment and transport. I will notify the school of any changes in writing and submit it to the clinic personnel.

Agree to be financially responsible for?*

Yes
No

Consent authorizing any representative of the school, in whose care my student has been entrusted, to present my student to an approved medical treatment center, and do consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, to be rendered to my student under the general practitioner, surgeon or dentist licensed to practice in any state in the United States. I agree to be financially responsible for my student's treatment. I will notify the school of any changes in writing and submit it to the clinic personnel.

Name of Person Completing Form

First Last

Relationship to Student*

By submitting this form, I hereby agree that I am the legal parent or guardian of this student. I have completed the above medical information and have indicated my preferences for my student's treatment

Student Shadowing Form

Student Information

Parent/Guardian Information

Physician Information

Dentist Information

Insurance Information

Student Health Service Consent