Visiting Student Form

How many Students are visiting?*
Student's Information*
First Last Current Grade
Any Allergies for this Student?*

Please include any medications being taken
Student #2 Information*
First Last Current Grade
Any Allergies for Student #2?*

Please include any medications being taken
Student #3 Information*
First Last Current Grade
Any Allergies for Student #3?*

Please include any medications being taken
Student #4 Information*
First Last Current Grade
Any Allergies for Student #4?*

Please include any medications being taken
Date of Visit*
MM slash DD slash YYYY
Emergency Release
By their signature(s) below, the parents/guardians of the Visiting Student hereby acknowledge and give consent for their child to spend the above-referenced school day at MCCS for the purpose of experiencing a typical school day at MCCS. The Visiting Student will participate in all classes and activities of their host student which may include physical education class, recess, lunch, etc. The Visiting Student will abide by all MCCS policies regarding behavior, dress code, etc. Pre-notification will be given to any/all affected staff members so that arrangements can be made for the Visiting Student to be accommodated. This release agreement does not apply to claims of intentional criminal misconduct or gross negligence by the school, its employees, or volunteers. If intentional or negligent conduct is proven in a court of law, I acknowledge and agree that I will hold harmless Mount Calvary Church and Mount Calvary Christian School, and all of its affiliated organizations, for any judgment or financial liability beyond the actual amount of liability insurance in force at the time of the occurrence.
In case of accident, illness, or other emergency, I request that the school contact:*
Name Relationship Phone
Who should we contact if we are unable to contact the person listed above?*
Name Relationship Phone
Consent
If the school cannot reach these persons or other parent or guardian after conscientious effort, I give permission for school staff to call paramedics or any other health care provider. If a life-threatening emergency exists, I give permission for school staff to call paramedics immediately and then contact the person above as soon as possible thereafter. By the signing of this form, I authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care which in the best judgment of the health care provider is deemed advisable. I agree to assume the financial responsibility for expenses incurred as a result or those services being provided. I also agree to be financially responsible for emergency medical transportation and all other costs related or associated with medical treatment. By signing below, I acknowledge that I have read and understand the rights and responsibilities described in this form. I further acknowledge that I agree to the terms listed above and that I intend to be legally bound by the term
Parental Permission for Participation: I have carefully read all the above information and understand its terms. I give permission for my son/daughter to participate and agree to the terms for this MCCS visit.*
Guardian 1 Name/Signature Guardian 2 Name/Signature
Household Information
Please provide the information requested below:
Email
Family Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Father's Employer*
Name Work Number Cell Number
Mother's Employer*
Name Work Number Cell Number
Physician*
Name Phone
Dentist*
Name Phone
Health Insurance Carrier*
Name Policy # Policy under the name of: Relationship
Preferred hospital*
Name
Please select the medications that you give permission for the school nurse to administer to your child(ren) only if determined to be needed.*
- I prefer no medication be given to my child unless a parent can be reached:
- Tylenol
- Motrin/Ibuprofen
- Tums
- Neosporin Ointment
- Visine eye drops
- Cough Drops
- Benedryl (rash, poison ivy, stings)
- Anbesol
- Caladryl lotion (for poison ivy)
- Sudafed (MS/HS only)
Medical Consent*
- I give permission for the school nurse to share any pertinent health information about my child(ren) to those teachers or faculty directly involved in his/her care.
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Visiting Student Form

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Emergency Release

Consent

Household Information