Student Emergency & Medical Form Please enable JavaScript in your browser to complete this form.STUDENT INFORMATIONPlease submit a NEW FORM for each additional student.Student's Name *FirstLastAge *3456789101112131415161718Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School *Grade *Preschool/Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeHigh SchoolParent/Guardian InformationIf there are two parents or guardians, please provide both below.Parent/Guardian 1 – Name *FirstLastEmail 1 *Phone 1 *Number where Parent/Guardian 1 can be reached during camp hoursParent/Guardian 2 – NameFirstLastEmail 2Phone 2Number where Parent/Guardian 2 can be reached during camp hoursWe sometimes use photos for the purpose of promoting the school and/or summer camp. *Yes, I give permission for the use of my child’s photo for promotional purposes.No, I do not give permission for the use of my child’s photo for promotional purposes.Out of State Immunization or Exemption Form Upload Drag & Drop Files, Choose Files to Upload You can upload up to 5 files. Required if your child’s immunization records are from out of state or to provide valid exemption form. Upload records here or ask the doctor’s office to send records to office@santafeschool.org or fax to 505-438-0080OTHER REQUIRED INFORMATIONTHIS INFORMATION IS NEEDED SO STAFF IS PREPARED TO GIVE THE BEST POSSIBLE CARE TO YOUR CHILD. Please provide a medical/behavioral plan as applicable.Does your child have any medical or other needs that require special attention? *YESNOSevere allergies, medication, seizures, autism, behavioral challenges, asthma, diabetes, etc.What medical needs does your child have?What symptom(s) should we be on the look for?If symptoms are observed, what should we do? This submitted form provides parent or guardian consent to follow provided instructions, including administration of medications. Please provide a step by step plan including medications to be administered and people to call with phone numbers. Any and all medications should be in the original container(s) clearly labeled with your child’s name. Please include instructions with any medication(s) in a Ziploc bag also labeled with your child’s name.Has your child been assessed for any medical or behavioral needs? *YESNOIf yes, please describe medical or behavioral needs.Does your child have any food restrictions that require special attention? *YESNOIf yes, please describe food restrictions.PICK UP & EMERGENCY CONTACT INFORMATIONThe following individuals ONLY are authorized to pick up my child at SFSAS. I understand that if I wish any other persons (including other parents) to pick up my child, I must speak with someone in the office requesting this change.Name 1 (Authorized to pick up)FirstLastOther than Parent/GuardianPhone 1 (Authorized to pick up)Relationship to child 1 (Authorized to pick up)Name 2 (Authorized to pick up)FirstLastOther than Parent/GuardianPhone 2 (Authorized to pick up)Relationship to child 2 (Authorized to pick up)EMERGENCY CONTACTSMust be 2 individuals OTHER THAN parents or guardiansName 1 (Emergency Contact) *FirstLastPhone 1 (Emergency Contact) *Relationship to child 1 (Emergency Contact) *Name 2 (Emergency Contact) *FirstLastPhone 2 (Emergency Contact) *Relationship to child 2 (Emergency Contact) *MEDICAL TREATMENT AUTHORIZATIONSanta Fe School for the Arts & Sciences will seek medical treatment and transportation for your child in case of a medical emergency. In the event of a medical emergency, 911 will be called and your child will be transported to the nearest hospital, accompanied by staff.Please select your Medical Treament Authorization *Yes, I authorize medical treatment for my child.No, I do not authorize medical treatment for my child.(Optional) Prefered Doctor or ClinicDISCIPLINE POLICY *I have read and agree to the terms of the Discipline Policy.Being part of the Arts & Sciences community means embodying our character traits of respect, trust, courage, compassion, honesty and stewardship. As an expeditionary learning school, we say, “We are crew, not passengers”. We are each responsible for one another’s well-being and for contributing to creating a positive and healthy learning environment. Click here to Read the Discipline Policy.Date Submit
