Christ Lutheran School

Skip to main content
Student Emergency Information 2017-2018

Please complete the form below. Mandatory fields are outlined in red.

Student's Information









Mother's (Or Step-Mother's) Information










Father's (Or Step-Father's) Information










Name of local person to contact if parent(s) is not available







Student's Medical Needs

  1. Needs EpiPen (Complete EpiPen Packet)
    Asthma

Names of persons authorized to take student from the campus




























Family Doctor's Information







Family Dentist's Information







Emergency Treatment Statement

If emergency treatment is required, and the parents or legal guardian cannot be reached immediately, your approval by checking the box in the space below empowers Christ Lutheran School authorities to exercise their own judgment in calling the physician indicated above and/or to transport the child to a hospital emergency room. Likewise, your approval by checking the box in the space below is not sufficient for the release of confidential information protected by Federal Law.

  1. By checking this box, I (We) agree to the Emergency Treatment Statement given above.
Permission to Participate In School Activities
And Permission For Emergency Medical Procedures

I hereby grant permission for my child to use all of the play equipment and to participate in all of the activities of the school.

I hereby grant permission for my child to leave the school premises under the supervision of a staff member or authorized adult (aged 21 or older) for neighborhood walks or for field trips in an authorized vehicle.

It is understood that every adult who assists as a driver for field trips or athletic events will have a valid California driver’s license, possess evidence of the legal minimum for insurance, and abide by applicable seat belt regulations.

I hereby grant permission for my child to be included in evaluations and pictures connected with the school program.

I hereby grant permission to the school and/or the agent of the school to administer medicine designated by me on the Request For Medication Form to my child. All medicine must be in the original prescription container, have the child’s name on it, with instructions clearly marked by the pharmacist or physician, and given to the office.

I hereby grant permission to the school and/or the agent of the school to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to, the following:

  • Attempt to contact a parent and/or guardian.
  • Attempt to contact the child’s physician.
  • Attempt to contact a parent and/or guardian through any of the persons listed on the Emergency Information Form.
  • If we cannot contact a parent and/or guardian or the child’s physician, we will do any or all of the following:
    • Call another physician or the paramedics.
    • Call an ambulance.
    • Have the child taken to an emergency hospital in the company of a staff member.
  • Any expenses incurred under Item 4 above, will be borne by the child’s family.
  • The school will not be responsible for anything that may happen as a result of false information given at the time of enrollment.
  1. By checking this box, I (We) consent to the Permission to Participate statements and the Emergency Medical Procedures.
Parent Handbook Acknowledgement

The Parent Handbook outlines policy and practice at Christ Lutheran School and informs students and parents about what is expected in a variety of situations. Reading this manual and being familiar with its contents is vitally important for the proper functioning of the school and for your understanding of the expectations we have of ourselves as well as that of each family represented. Therefore, we request that you not only carefully read this publication, but that you also check the box indicating that you indeed received a copy of the Parent Handbook.

  1. By checking this box, I (We) acknowledge that I (We) have received a copy of the Parent Handbook.