Summer School Registration
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Home Address

Student Address
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Parent 1

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Parent 2

 
 
 
 
 
 
 

Session 1

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Session 2

 

Session 3

 

Total Amount

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Health Information

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Physician

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Physician Address
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Terms: In the event that the contacts listed on the Registration Form are not available or cannot be contacted, I authorize the Principal to authorize such medical attention that may be deemed appropriate.

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Anaphylaxis Emergency Plan

Anaphylaxis Emergency Plan

Emergency Action Plan: (To be filled in by parent/guardian)
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Claremont School Staff Roles and Resposibilities

  • Adhere to Claremont School’s Anaphylactic Policy
  • Staff will conduct a check to confirm child(ren) have their medication with them before each transition, (i.e. moving from the classroom to the gym, leaving for field trip, etc.)
  • Administer medications and/or instructions as set out in child’s Individual Plan and Emergency Procedures.
  • Staff is to remain with child until parent or guardian arrives.
  • Staff will ensure administered epi-pen is given to parents or hospital for disposal.
  • Written report to be filled out by staff dealing with emergency.
  • Serious Occurrence Report to be filed

Parent Agreement

I acknowledge my participation in the development of the preceding Emergency Action Plan and agree to execute reliably the parent commitments listed within it. I give my consent for the staff of the Claremont School to execute the child care commitment as outlined within the plan. In the event of an emergency, I authorize the school staff to administer the designated medication and obtain medical assistance. I agree to assume responsibility for all costs associated with medical treatment and absolve the Claremont School and its employees/volunteers of responsibility for any adverse reaction resulting from administration of the medication.

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Emergency Contact Information in the event of an anaphylaxis reaction

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Parent 1 details will be used with the credit card.
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