Enrollment / Emergency Information / Field Trip Permission / Media Release Form printable pdf download

FREMONT MIDDLE SCHOOL

Enrollment / Emergency Information / Field Trip Permission / Media Release Form

Student Full Legal Name: _________________________________________ Grade: ______________ Date of Birth:__________________

Address __________________________________________ City ____________________________ Zip _____________________________

County: _______________

Township: ___________________

Email Address:______________________________________________

Male [ ] Female [ ] Race: ____________

What school district do you live in: _______________________ Primary Language: _____

Birthplace (City and State): ________________________________ Previous School

_______________________________

Name/City/State:

Student lives with:

[ ] Both Parents

[ ] Mother

[ ] Father

[ ] Guardian/Ward of the Court

[ ] Other

[ ] Step Parent

Family Data (circle ones that apply)

Mother/Guardian/Step/Legal

Father/Guardian/Step/Legal

_______________________

_____________________

Name

Place of Employment

________________________

Home Phone

______________________________

_____________________________

Cell Phone

___________________________

__________________________

Work Phone

___________________________

__________________________

If there are any siblings or step/siblings please indicate their name, school they attend and current grade: If more add on back of form.

____________________________________

_____________________________________

______________

Siblings Name

School Currently Attending

Grade

____________________________________

_____________________________________

______________

Siblings Name

School Currently Attending

Grade

List two and please do NOT include yourself or spouse.

EMERGENCY CONTACTS:

__________________________________________________

Name/Relationship and Phone Number

Special Education Services: Is there an active IEP: Yes __ No __

Will any medication need to be given at school? YES __ NO__

Does your child have any health problems/allergies: __________________________________________________________________________

If any prescription medication needs to be administered at school (including inhaler’s and epi pen’s) a permission

slip from the school office MUST be signed by a parent A ND doctor PRIOR to medication being administered.

Over the counter medication to be administered at school a parent MUST complete the form in the office PRIOR to

medication being administered. Students are NOT ALLOWED to carry ANY medication on them OR kept in their

locker.

Is this applicant currently under expulsion or suspension from another school? Yes______ No ______

The child described above has my permission to participate in and attend any school sponsored filed trip for the school year _____________. I understand that

when there is a school sponsored trip, my child will be accompanied by, and will be under the direct supervision of school personnel. I agree that the school

and/or school personnel are not to be held liable for damages caused by my child or any accident or injury sustained by said child. I also understand that I may or

may not be notified prior to a field trip taking place. I certify that I am the parent/legal guardian and have legal custody of the above student and that all the

information on this form is correct. If the school is unable to reach me, I hereby authorize the school to call the physician designated below and to follow his/her

instructions. If it is impossible to contact this physician, the school many make whatever arrangements deem necessary. DR:_____________________________

If your child is photographed as part of a school related activity, we would like your permission to use the photo in materiel the school district develops for your

school and community communications. (Example: School Matters, Yearbook, middle school publications, newspaper, etc.)

______ Yes, I give permission to use my child’s photo.

______ No, I do not give permission to use my child’s photo in school related publications.

_________________________________

_____________________________

_____________

Parent/Legal Guardian Signature

Relationship to Child

Date