PARENT NOTIFICATION
EMERGENCY MEDICAL & STUDENT RELEASE AUTHORIZATION
MAIN CONTACTS: In case of an emergency with your student, the school office will call and notify you at the primary phone number provided. If you are not reached at the primary number, phone calls will be made to the contacts and phone numbers listed below in the order given until someone is notified. The same procedure will be used each day after 9 a.m. if your elementary student or Harding Middle Schoolstudent is absent and the school has not been notified. Automated attendance calls are used at Garfield Middle School and LHS.
Child’s Name ______Grade ______
Address: ______Primary Phone: ______
West Shore Program ______
Place an X in one or both columns at the far right for the contacts for whom you allow to authorize emergency medical treatment for your student and to whom your student may be released.
Print Full Name / Home Phone / Work Phone / Cell Phone / EmergencyMedical / Student Release1stContact/Relationship / ( ) / ( ) / ( )
2nd Contact/Relationship / ( ) / ( ) / ( )
3rd Contact/Relationship / ( ) / ( ) / ( )
4th Contact/Relationship / ( ) / ( ) / ( )
PART 1 – TO GRANT CONSENT
In the event reasonable attempts to contact me at the above numbers have been unsuccessful, I hereby give my consent for: (1) the administration of any treatment deemednecessary by:
(Physician) Dr. ______, Address ______Phone (___)______,
(Dentist) Dr. ______, Address ______Phone (___ )______,
Or in the event the designated preferred practitioner is not available, by another licensed physician or dentist: and
(2) the transfer of the child to preferred hospital: Lakewood Fairview
If the emergency is such that your child needs immediate attention, he/she will be taken to the most accessible of these hospitals. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity of the surgery, are obtained before the surgery is performed.
Facts concerning the child’s medical history including allergies, medications being taken, food supplements, modified diets, fluoride supplements, and any physical impairment to which a physician should be alerted:______
______
Date:______Parent Signature:______
PARENT NOTIFICATION
EMERGENCY MEDICAL & STUDENT RELEASE AUTHORIZATION
If You Completed Part 1 On Page 1 – Do NOT Complete Part 2 in Box Below
PART 2 – REFUSAL TO CONSENT
In the event reasonable attempts to contact me at the above numbers have been unsuccessful, I DO NOT
give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take no action, or to:
Date:______Parent Signature:______
ALERTNOW SYSTEM PARENT NOTIFICATION & EMAIL COMMUNICATION
MASS PARENT NOTIFICATION: The District uses the AlertNow Notification System to inform parents about emergencies, school closings, events and other important information that either the District or school building needs to relay to families. The AlertNow system can send phone, email and text messages.
Phone calls and text messages: These will be used to communicate an emergency situation, school closings and delays as well as select important school or districtwide reminders. In the case of an emergency, including school closings, the student’s primary phone number and up to three additional phone numbers listed for the student will be called and text messages sent. Please list any additional phone numbers besides the primary phone that should be included in this notification process:
1.______2.______3.______
In an emergency, if you choose, the district will also notify your student’s cell phone with a text message to the phone number you provide below for your child:Student’s cell #: ______(optional) Parent/Guardian initials ______
Automated Attendance Calls:These calls will be made for Garfield MS and LHS students to notify parents/guardians when a student has been absent from one or more classes. Please provide a phone number at which you would like to receive these calls, if necessary, or your primary phone number will be used: Attendance # ______
Emails: Emails will be used to communicate all other types of information, at the discretion of the building principal and other District personnel. The sender on these emails will be listed as “Lakewood City Schools.”
AUTHORIZATION FOR EMAIL COMMUNICATION:In addition to school newsletters and District web site, the main method of communication with families will be via email. While e-mail may be an efficient communication tool, it should not be assumed that email correspondence is entirely private and confidential. The District undertakes a numberof measures to ensure the security and integrity of its technological resources. When email travels over the Internet,unauthorized individuals may be able to access an email exchange between a parent and a teacher. Additionally, an email may be forwarded to the wrong person or email address. Therefore, in the circumstances of parent-teacher communication, it may still be best for parents to use face-to-face meetings or phone calls when informing a teacher of particularly sensitive material or asking a teacher to provide the same.
To protect the privacy of students, the District requires all teachers to abide by an Acceptable Use Policy that governs use of the District’s technological resources, including email correspondence. Therefore, any parent who wishes to communicate with their child’s teacher via email must authorize such communication by providing an email address to be used by the teacher and agreeing to the terms below.
Subject to these understandings, I wish to communicate with my child’s teacher via email. The following email address is the address that I wish any email correspondence relating to my child(ren), to be sent to:
E-mail Address #1:
E-mail Address #2:
I understand that these will be the email of record for all District-related communication. I understand that the teacher may not respond to inquiries I make from any other email addresses. I agree that if an email address I have provided changes for any reason, I will notify my child’s school immediately and complete another Authorization for Email Communication form.
The parent, guardian, or student, 18 years of age or older, executing this agreement acknowledges that the District is not responsible if third parties access electronic communications after any such information has been sent by the District using the email address stated herein. The parent, guardian or student, 18 years of age or older, agrees to indemnify, defend and hold harmless from and against any claims, actions, demands and judgments against the District resulting from communicating through email involving the child listed below and as authorized herein.
Name of Parent/Guardian or Student (18 years of age or older)
(Please print) ______
Signature: ______Name of Child:______