Microsoft word - austin deep student emergency care and contract forms

Name___________________________________ Birth date:_____________________ Home School_______________________ Address:_________________________________ Home Ph#_____________________ Mother’s Name____________________________ Cell #_________________________ Place of Business___________________________ Business Ph#___________________ Father’s Name_____________________________ Cell#_________________________ Place of Business___________________________ Business Ph#___________________ If parents are divorced, custodial parent is _____________________________________ Doctor____________________________________ Phone #_______________________ Dentist____________________________________ Phone #_______________________ Responsible parties to be called if parents cannot be reached: 1. Name______________________Relation_______________Ph#_________________ 2. Name______________________Relation_______________Ph#_________________ 3. Name______________________Relation_______________Ph#_________________ Permission for Emergency Treatment in School Clinic Permission to call doctor if parents or responsible parties cannot be reached IN AN EMERGENCY Permission for Emergency Care at ___________________hospital (Name of hospital) Conditions requirement SPECIAL CARE: Allergy______________________________________________ *If you have listed a food or insect allergy for your child, please bring liquid Benadryl to the clinic with a completed parental permission form and a physician’s note giving permission for the Please list any ACCIDENTS/ administration of Benadryl at school as needed Eye Problems_________________________________________ ____________________________ Eye Corrections________________________________ Hearing Problems______________________________________ ____________________________ Hearing Corrections_____________________________ Asthma______________________________________________ ____________________________ Bone or Muscle________________________________________ ____________________________ Heart________________________________________________ Daily Medications______________________________________ Medications sent to school_______________________________(requires special permit) Seizures______________________________________________ Other________________________________________________ PARENT’S SIGNATURE:________________________________________________________________ (All medications needed by a student must be held by the office staff and kept in the original container. No kind of medication, either prescribed or over-the-counter, may be given without the completion of this form. If medication is not
necessary, please fill in your child’s name and across the form put DOES NOT APPLY and then sign, date, and return
this form).
Student’s Name:______________________________________________________________________ Physician’s Name:____________________________________________________________________ Date:________________________________________________ Name of Medication:__________________________________________________________________ Dosage:_____________________________________________________________________________ Directions for Administering:___________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Parent’s Signature:______________________________________________ The following persons have permission to pick up your child from Austin DEEP 2012: _________________________________________ ________________________________________________ _________________________________________ ________________________________________________ Acceptable Use Policy for Equipment and Services
Austin DEEP students may be enrolled in classes that involve the use of technological and media equipment and services. The hardware, software, cameras, editing machines, production and broadcast equipment, and Internet access is a benefit that is offered by the host school for Austin DEEP students. As visitors to the school, it is very important that Austin DEEP students understand their responsibilities and limitations. The following guidelines MUST be followed at all times. Failure to follow these guidelines can result in loss of privileges; removal from the program, and/or other measures as deemed appropriate by Austin DEEP personnel, school personnel, and other authorities. User Guidelines: Log on the network only as yourself. Do not share your password with anyone. You are responsible for all actions made under your account. All users are expected to respect the rights of others. Never read, delete, alter, copy or modify any other students’ or teachers’ files. Using someone else’s password or posting a message using another person’s login name or identity is a form of dishonesty. Attempts to login as any other user will result in loss of computer privileges. Users are personally responsible for their own actions while accessing and utilizing the school’s computer resources. Students are advised never to access, keep or send anything that they would not want their parents or teachers to see. Users must not release their own or anyone else’s personal information on the Internet including name, address, phone number, and photograph. Users are expected to take the utmost care of computer and network resources. This includes, but is not limited to vandalizing any equipment or software, altering or removing any hardware or software, changing printer settings, desktop settings, or uploading or creating computer viruses. If a user identifies or has knowledge of a security problem on the network, the user must notify an administrator or teacher immediately. The security problem should not be shown or demonstrated to other users. Users may not download, copy or install any computer programs without the expressed consent of the technology department at the host school. Users are expected to follow all copyright laws. They must not copy software, music, or multimedia. Commercial software is copyrighted and each purchaser must abide by the licensing agreement published with the software, music, or multimedia. Users are expected to notify school officials immediately of any user who is accessing or disseminating inappropriate material, attempting to disable the filtering software, or using the Internet or the network in an inappropriate manner. Internet access is expected to be used to provide learning and teaching consistent with the educational goals of Austin DEEP. Use of the network and/or Internet for financial, commercial, or political purposes is prohibited. No external e-mail accounts are to be used on campus. Chat rooms and instant messaging are not to be used. We understand the guidelines stated above, and agree to use the equipment and services appropriately. I also give my permission for my child to have supervised access to the Internet. ________________________________________ ________________________________________ Theme-“Jump DEEP Into Teaching Others” June 11 – 29, 2011 at Holy Family Catholic School As a Distinguished Scholar attending Austin DEEP, I agree to abide by the following guidelines of the program. I understand that if these rules are not followed, I will be dismissed from the program. I hereby agree to: • Follow all the rules of the Austin DEEP Program at Holy Family Catholic School; • Treat other people with respect and cooperate with faculty and other students at all times; • Clean up and not litter the building or grounds of Holy Family Catholic School; • Follow through on all my projects, using my time to the fullest. I completely understand that if I am disruptive to my class, my behavior will be considered unacceptable and I will be dismissed from Austin DEEP without refund to my parents. __________________________________________ __________________________________________

Source: http://csdatx.org/wp-content/uploads/2012/02/Austin-DEEP-Student-Emergency-Care-and-Contract-Forms.pdf