REQUIRED FORMS

Kindergarten
___ Immunization form ___ Health Appraisal form (signed by doctor) ___ Copy of birth certificate ___ Emergency Contact form ___ Transportation Policy and Agreements ___ Permission to Publish ___ Emergency Treatment/Medical Information ___ ID Information ___ Waiver/Indemnity form ___ Film Permission ___ Handbook Read and Accept form ___ Release of Medication (if applicable) ___ Daycare sign-up (if applicable) ___ Release of Medication (if applicable) ___ Daycare sign-up (if applicable) ___ Athletic Participation/Emergency forms (if applicable)

5th grade
___ Health appraisal form (signed by doctor) ___ Emergency Contact form ___ Emergency Treatment/Medical Information ___ Transportation Policy and Agreements ___ Permission to Publish ___ ID Information ___ Waiver/Indemnity form ___ Film Permission ___ Handbook Read and Accept form ___ Release of Medication (if applicable) ___ Daycare sign-up (if applicable) ___ Athletic Participation/Emergency forms (if applicable)

1st-3rd grade
___ Emergency Contact form ___ Emergency Treatment/Medical Information ___ Transportation Policy and Agreements ___ Permission to Publish ___ ID Information ___ Waiver/Indemnity form ___ Film Permission ___ Handbook Read and Accept form ___ Release of Medication (if applicable) ___ Daycare sign-up (if applicable)

6th-8th grades
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ PE/Athletic Health form Emergency Contact form Updated Immunization form (7th grade) Emergency Treatment/Medical Information Transportation Policy and Agreements Permission to Publish ID Information Waiver/Indemnity form Film Permission Handbook Read and Accept form Release of Medication (if applicable) Daycare sign-up (if applicable) Athletic Participation/Emergency forms (if applicable)

4th grade
___ Emergency Contact form ___ Emergency Treatment/Medical Information ___ Transportation Policy and Agreements ___ Permission to Publish ___ ID Information ___ Waiver/Indemnity form ___ Film Permission ___ Handbook Read and Accept form

REDEEMER LUTHERAN SCHOOL2011/2012

EMERGENCY CONTACT FORM

LAST NAME _____________________________

HOME PHONE ________________

CHILD NAME _____________________________ GRADE _________ CHILD NAME _____________________________ GRADE _________ CHILD NAME _____________________________ GRADE _________

FATHER _________________________________ EMPLOYER ______________________________ WORK PHONE ___________________________ PAGER _________________________________

OCCUPATION ________________________________ TITLE _______________________________________ CELL PHONE _________________________________ EMAIL ADDRESS _____________________________

MOTHER _______________________________ EMPLOYER _____________________________ WORK PHONE __________________________ PAGER ________________________________

OCCUPATION ________________________________ TITLE _______________________________________ CELL PHONE _________________________________ EMAIL ADDRESS _____________________________

DOCTOR _______________________________

PHONE NUMBER _____________________________

IF AN EMERGENCY ________________________________________________________________________ RELATIONSHIP ________________________ PHONE NUMBER ______________________________

People authorized to pick up my child (ren):

Name ________________________________ Phone # ______________ Relationship _____________ Name ________________________________ Phone # ______________ Relationship _____________ Name _________________________________ Phone #_______________ Relationship ____________ Name _________________________________ Phone #_______________ Relationship ____________

Permission to publish in school directory: Cell phone numbers ____Yes ____ No

Please contact the school office if someone not on your authorized list will be picking up your child. Picture ID required.

EMERGENCY TREATMENT/MEDICAL INFORMATION SCHOOL YEAR 2011/2012

(One form per child)

STUDENT NAME _____________________________

GRADE ________________

I PERMIT A STAFF MEMBER OF REDEEMER LUTHERAN SCHOOL TO AUTHORIZE TREATMENT IN MY ABSENCE. ____ ____ ____ I give permission for the school office to give my child Tylenol or Ibuprofen when needed Dosage ____________________________ I do not give the school office permission to give my child Tylenol or Ibuprofen Please call before administering Tylenol or Ibuprofen

MY CHILD TAKES THE FOLLOWING MEDICATION:

Medication ____________________________________________________________________________ _____________________________________________________________________________________

KNOWN ALLERGIES:
______________________________________________________________________________________________ ______________________________________________________________________________________________ _______________________________________________________________________________________________

PARENT OR GUARDIAN SIGNATURE ___________________________________________________

UNIFIED HEALTH APPRAISAL FORM

Redeemer Lutheran School ______________________________________________________________________ TO PHYSICIANS: This Unified Health Appraisal form may be use for reporting any or all of the
following: (1) Physical Examination (2) Activity Restrictions (3) Medications to be taken at school (4) Recommended remedial or follow-up services (5) Athletic camp or other examinations.

TO THE SCHOOL: This Unified Health Appraisal form and Immunization record should become
a permanent part of each students cumulative record folder. A copy should be made and sent to the new school whenever a student transfers. Name _______________________________________________ Date of Birth _______________ Parent(s) or Guardian _____________________________________________________________ Address _____________________________________________________________ Sex F M

Phone __________________________ Emergency Phone ______________________________ Visual Acuity: Right 20/ _____ Left 20/ _____ With correction _____ Without Correction _____ 1. The above name patient was examined on (Date) ________________ and found to Be free of illness or conditions which would interfere with Scholastic performance. Be free of illness or conditions which would interfere with Sports participation. Have the following Medical Conditions: 1. ______________________________ 2. _____________________________ 2. The following Restrictions should be placed on Activity: None See Below

1. ______________________________ 2. _____________________________ Restrictions are to in force until (Date) _______________________________________ 3. See attached sheet for medications to be taken at school. 4. Other recommendations: 1. _____________________________ 2. _____________________________ Physicians Name _____________________________________ Phone __________________ Address _____________________________________________________________________

Physicians Signature __________________________________ Date _________________ __

REDEEMER LUTHERAN SCHOOL BUILDING CARING AND SHARING DISCIPLES

2011-2012 Waiver and Indemnity Agreement Redeemer Lutheran School is a ministry of Redeemer Lutheran Church. I hereby permit Redeemer and/or it agents to take my child, ______________________________ to functions, lunches, sports outings, and other field trips beyond the campus. I understand I will be given prior notification of such field trips. In the transport of my child to and from these activities, I release you from any and all liability in the event my child is injured during an accident associated with Redeemer or its agents. In the acceptance of my child as a student at Redeemer and having satisfied myself that supervision and attention to safety are prudent and reasonable. I agree to identify, defend, and hold harmless Redeemer and its agents, employees, and representatives against any and all claims and demands (including legal fees) made by me, my spouse, or the legal guardian of the child on behalf of the child. In case of illness or accident I give Redeemer permission to provide any emergency care for my child deemed necessary, including, but without limitation, treatment by public or private facilities or personnel. It is understood that a conscientious effort will be made to locate me (or the emergency contact persons designated by me) before any action is taken. I accept and agree to pay any charges incurred by Redeemer in such care. If my child has a clinical health condition (e.g., severe food allergies, asthma, diabetes, or seizures), I am responsible for submitting a Care Plan which stipulates special needs prior to the first day of school. I hereby permit Redeemer to allow my child to view television and videos within reasonable limits as deemed beneficial to Redeemer. Viewing will be done in accordance with the curriculum, with a specific learning purpose and/or recreation. I understand videos shown to my child will primarily be "G" rated. If any are "PG" rated or unrated containing sensitive materials, I will first receive a separate form by which I give my permission. During computer classes, I understand my child will have supervised access to the Internet for educational purposes, and will be given instruction and admonition as to what is appropriate for Christians to view on-line. Any child who fails to use the Internet in a responsible, ethical, efficient, and legal manner will have his/her access revoked. I understand that Redeemer is not responsible for any item my child(ren) brings to school that are lost, stolen, or broken while on school premises. I have read and understand the Waiver and Indemnity Agreement, and have willingly placed by signature below as evidence of my acceptance of all the conditions contained herein. I further attest that I have full authority as parent or legal guardian of the above child to enter in to this agreement. Parent or legal guardian signature: ______________________ Date: ________ Parent or legal guardian signature: ______________________ Date: ________

ID INFORMATION CARD
Redeemer Lutheran School2011/2012 ____________________________________________________
Name _____________________________________________________________ Height _______ Weight __________ Address ____________________________________________________________ City _____________________ State ______ Zip ________ Phone ____________ Insurance Name and ID Number __________________________________________ Nearest Relative _______________________________________________________ Address ____________________________________________________________ City _____________________ State ______ Zip ________ Phone ____________ Medical Information _____________________________________________________ Allergic Information _____________________________________________________

ID INFORMATION CARD
Redeemer Lutheran School2011/2012 ____________________________________________________
Name _____________________________________________________________ Height _______ Weight __________ Address ____________________________________________________________ City _____________________ State ______ Zip ________ Phone ____________ Insurance Name and ID Number __________________________________________ Nearest Relative _______________________________________________________ Address ____________________________________________________________ City _____________________ State ______ Zip ________ Phone ____________ Medical Information _____________________________________________________ Allergic Information _____________________________________________________

Redeemer Lutheran School2011/2012 ____________________________________________________________

Last Name ________________________ Date of last physical exam ____________ First Name ______________________ Date of Birth _____________________

PE AND ATHLETICS HEALTH FORM

Since his/her last physical exam, has the student: (circle number of any yes categories) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) Has surgery Been hospitalized Been under a physicians care for health care problem(s) Had a serious illness Had an injury requiring physicians care Had an episode of unconsciousness Experienced dizzy spells of blackouts Started taking any new medications-prescriptions or over-the-counter Developed any new drug allergies Had any episodes of unexplained shortness of breath, wheezing or chest pain Developed any new health problems Started wearing contact lenses

Please explain all yes answers _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ In my opinion, my son/daughter does ____ does not ____ need to have another physical examination prior to participation in PE or the Athletic program. Parent or Guardian Signature ____________________________ Date ____________ ******************************************************************************************************** Lower portion to be completed by school personnel only
This form completed by parent was reviewed on (date) _____________________________ By (name) ________________________________________________________________ The following recommendation is made: _____ Cleared for participation _____ Reevaluation physical examination needed

RELEASE OF MEDICATION FORM

Redeemer Lutheran School2011/2012 _________________________________________________________________ Parental Release For Administration of Medication to Pupils (Signed and returned only if your child needs to have medication during the school day)

Also, please fill out if your child will be carrying an inhaler for asthma.

No medication will be given to students without a properly signed permission form!

In order for our son/daughter ____________________________________________ To participated in the regular school program, our physician has recommended that medication be administered. I hereby grant permission for properly designated school personnel to administer medication to my child.

Parent or Guardian Signature ____________________________________________ Telephone number ____________________________ Date ___________________

(must have physician signature if prescription medication)

Physician prescribing medicine ____________________________________________ Telephone number _____________________________________________________ Approximate time medication should be administered __________________________ Dosage _________________ Type of medication ___________________________

Medication Dosage Information

PLEASE FILL OUT BOTH SIDES OF THIS FORM!

SPORTS EMERGENCY INFORMATION FORM

Redeemer Lutheran School2011/2012 ____________________________________________________________

Name _______________________________________________ Boy _________ Girl __________ Address _________________________________________________________________________ Age ________ Birthdate _____________________ Weight ___________ Height ___________ Childs Physician __________________________________________________________________ Address _________________________________________________________________________ Alternate Physician ________________________________________________________________ Preferred Hospital (if necessary)______________________________________________________ Parent or Guardian __________________________________ Home Phone __________________ Parent or Guardian __________________________________ Home Phone __________________ Friend or Relative ___________________________________ Telephone ____________________ Allergic to what medication __________________________________________________________ ________________________________________________________________________________ Other information you feel important for a doctor to know ___________________________________ ________________________________________________________________________________ ________________________________________________________________________________ As required by Redeemer Lutheran School, my child has received a physical examination. A copy is on file in the school office. Parent or Guardian Signature _________________________________ Date _________________ ******************************************************************************************************************* I give my permission for the person in charge to physical education or the sports program, at the specific time of the injury, to do what they feel is necessary for the well being of my child. I give permission to my child to participate in the athletic program and its contests if he/she so desires and I understand that travel will be school or private vehicles. Parent or Guardian Signature ___________________________________ Date __________

PLEASE FILL OUT BOTH SIDES OF THIS FORM

PLEASE FILL OUT BOTH SIDES OF THIS FORM!

PARENT PERMISSION
(Please initial all items)
______ Yes my child has permission to participate in the after school sports program with Redeemer Lutheran School. If I cannot transport my child to a ball game or practice off of the Redeemer grounds, and have not made other arrangements, my child has permission to ride with another players parent or relative, coach, or other staff person. I will help others with transportation whenever possible. I understand that if my childs transportation is not at the game or practice site when the activity is finished, I need to pick up my child at Redeemer, as he/she will be taken back to school (granted there is a way to get them back to school). I will read the weekly newsletter, looking for information on the athletics, such as game locations and times. This will allow me to make arrangements for my child so that he/she is not late getting picked up. (If someone is late, it is an inconvenience to the coach or staff person that has to wait with your child.)

______

______ ______

______

My child and I, both understand the athletic philosophy and eligibility rules (found in the Parent HandbookPage 8) for extra curricular activities. We will abide by both of these outlines.

Parent Signature ____________________________________________________

Student Signature ___________________________________________________

PLEASE FILL OUT BOTH SIDES OF THIS FORM

Redeemer Lutheran School

1955 E. Stratford Ave. Salt Lake City, UT 84106

Driver of Private Vehicle Transportation Policy and Agreement

This record is to be completed prior to a parent, guardian or other approved adult over the age of 25 providing transportation for students from the school to approved school events throughout the 2010-2011 school year. Drivers Name: _________________________ Utah Drivers License # ___________________ Expiration Date: _________________________ Drivers Name: __________________________ Utah Drivers License # __________________ Expiration Date: ________________________

Insurance Company: ______________________________________________________________ Policy #: _______________________________ Expires: _______________________________

This agreement will be kept in the official school records and not available for public use. All approved drivers must have a valid Utah Drivers license in their possession and attained the age of 25. The driver may not drive if the license has been confiscated in conjunction with a ticket. Drivers must be a parent or a guardian of a student enrolled at Redeemer Lutheran School or an approved supporter or booster of Redeemer Lutheran School. Any person with an alcohol or drug related driving violation within the past 10 years or any person with more than 2 moving violations in the past 12 months will not be allowed to be a driver. Redeemer Lutheran School reserves the right to obtain background checks. Each vehicle must have liability insurance coverage prior to being used to transport children. The responsibility is not assumed by Redeemer Lutheran School. Drivers must assure that there are operable seat belts in the vehicle and that each child is properly restrained with the seat belt when the vehicle is moving. Drivers must ensure that the vehicle is properly licensed and has passed Utah state required safety inspections. A copy of my drivers license is on file in the school office. Completion of the form does not provide automatic authorization to be a driver or to transport children in connection with a Redeemer Lutheran School activity.

I HAVE READ AND UNDERSTAND THE ABOVE REQUIREMENTS. I AGREE TO ABIDE WITH THEM.
Signature of Driver(s): ___________________________ _________________________________ Date ___________________ Date ______________________

Please attach a copy of your Drivers License and Insurance card.

Student Permission to Publish

2011-2012

Consent
I do hereby give Redeemer Lutheran School the right to use my first name, photograph, and any published project for reproduction for use by Redeemer Lutheran School. I understand the above will only be used for activities related to Redeemer Lutheran School. Students Printed Name _________________________________________ Students Signature __________________________________ Date ____________

Parent/Guardian Consent
I am the parent/guardian of the above named minor and hereby approve the foregoing and consent to the use of first name, photograph, and published project to the pursuant terms mentioned above in the following: (Please check) ___ ___ ___ Redeemer Lutheran School brochures Redeemer Lutheran School website Newspaper or other published articles

I affirm that I have the legal right to issue such consent. Parents Printed Name _________________________________ Parents Signature ________________________________ Date _____________

Parent/Guardian Denial
I am the parent/guardian of the above named minor and hereby do not give permission to the use of first name, photograph, and published project to the pursuant terms. Parent Signature _________________________________ Date ______________

REDEEMER LUTHERAN SCHOOL AFTER SCHOOL CARE AGREEMENT

After school care at Redeemer is an extension of the school day for those students and families who are in need of its services. We believe that our students are our most valuable resource. To that end, our goal is to provide quality childcare that is nurturing, dependable, and recognizes the special needs of the school age child. The program will include the following options for our students: Study Hall - available Monday-Thursday - 3:30-4:30 p.m. The children are provided a quiet classroom environment in which to work independently on their homework. This is only for grades 3-8. After Care Program - available Monday-Thursday - 3:15-6:00 p.m.; Friday - 2:15-6:00 p.m.; and all half days. Snacks are provided daily. Games, activities and outdoor play are part of the curriculum. All Redeemer Lutheran School rules apply in our after school care program. All students will be logged in to the after school care program regardless of which location they attend. It is necessary that parents sign out their children in the basement classroom when they pick them up. Students who are not signed out by a parent will be billed as if picked up at 6:00 p.m. Students not picked up by 6:00 p.m. will be billed at $1.00 per minute. No after school care is provided on the first and last day of school. Rates are as follows:

$4.00/hour or portion of an hour beginning at 3:15 p.m. There is no charge for students picked up by 3:30 p.m. (2:30 p.m. on Friday). Students not picked up by 3:30 p.m. will automatically be charged for the first full hour. $160.00/month (for nine payments).

Please sign up for one of the rates on the attached form. To ensure the safety of all our students, children in the building after 3:30 p.m. must go to after school care. They will be enrolled in the after school care program and billed at the hourly rate unless they have the monthly plan. Please sign up for one of the rates on the attached form.

BEFORE SCHOOL CARE

Parents may drop children off at school beginning at 7:30 a.m. each morning. Children who arrive between 7:30-8:00 a.m. must report to the posted before school care classroom. The charge for Before School Care is $3.00.

REDEEMER LUTHERAN SCHOOL AFTER SCHOOL CARE SIGN-UP

Student Name ______________________________________ Grade ___________ Student Name ______________________________________ Grade ___________ Student Name ______________________________________ Grade ___________

Method of Payment (Check one)

______ $4.00/hour ______ $160.00/month

Your signature below indicates that you agree to fulfill all financial obligations for the after school care program and will sign your child out of the program each day that he/she is enrolled.

Parent Name ___________________________________________________

Parent Signature ________________________________________________ Date __________________

Redeemer Lutheran School Film Permission School year 2011-2012

Home room ________ Student Name________________

Throughout the school year the school curriculum is augmented with films. These films will always be reviewed for appropriate content for grade and age level prior to showing. This parental permission will allow Redeemer Lutheran School to show PG rated films without having a specific permission authorization for each film. If you agree with this school year permission for your child to view PG rated films please sign and date the appropriate statement below. Explanation of Movie ratings from www.filmratings.com Parental Guidance Suggested. Some material may not be suitable for children. This signifies that the film rated may contain some material parents might not like to expose to their young children- material that will clearly need to be examined or inquired about before children are allowed to view the film. Explicit sex scenes and scenes of drug use are absent; nudity, if present is seen only briefly, horror and violence do not exceed moderate levels.

I give my permission for my child to view PG rated film for the 2010-2011 school year.

Printed name_________________ Signature _________________ Date __________

If you do not want to give school year permission for PG rated film, Redeemer Lutheran School will communicate with you regarding the name of the film to obtain your decision about viewing that film. The communication may be phone, internet email, FAST DIRECT mail, note from the teacher or person to person with school staff.

I do not give permission for my child to view PG rated film for the 2010-2011 school year. I want to know the title of each film before I give permission.

Printed name_________________ Signature _________________ Date __________

XII. PARENT AND STUDENT STATEMENT OF ACKNOWLEDGEMENT This is to acknowledge that I have received a copy of Redeemer Lutheran Schools parent handbook. I understand that it provides guidelines and summary information about Redeemers policies, procedures, and rules. I also understand that it is my responsibility to read, understand, become familiar with, and comply with the standards that have been established. I further understand that Redeemer reserves the right to modify, supplement, rescind, or revise any policy from time to time, with or without notice, as it deems necessary or appropriate.

The Board of Christian Education has modified the School Attendance Policy. Please read the policy below before signing the acknowledgement agreement. Please read the entire handbook to be aware of all updates and changes.
Attendance If your child is to receive maximum educational benefits, it is imperative that school attendance be regular and punctual. School is in session 180 days each year between 8:30 a.m. and 3:15 p.m. Monday through Thursday, with Friday dismissal at 2:15 p.m. Parents are to notify the school office by 9:00 a.m. if their child is to be absent. If the school does not hear from a parent whose child is absent the school will call to verify the absence. All absences from school are to be reported to the school office via a written note. Students must be in school for a minimum of four hours in order to meet the daily attendance requirement. Vacations or trips out of town which necessitate your child being absent from school are discouraged. The instruction and classroom discussion that is missed is vital to learning. Tardies Parents should see to it that their children arrive early enough so that they are ready to begin school at 8:30 a.m. If children are late they should proceed directly to the office to pick up an arrival slip so they can be admitted into the classroom. If students are more than 15 minutes late parents need to come to the school office and "sign in" their child(ren). 1. Five tardies count as one absence. Students may not earn the Perfect Attendance Award, if they receive more than five tardies for the school year. 2. After five tardies, Parents will be assessed a $5.00 per tardy fee. 3. Tardies due to medical appointments require a note from the medical professional. ( Note: There are 180 school days and students must attend all of these in order to earn the Perfect Attendance Award.) 4. Excused tardies include doctor and dentist appointments or any appointment approved by the classroom teacher. 5. Parents will also be notified via Fast Direct by the school office following the students fifth unexcused tardy. While it is sometimes necessary to take children out of school for medical appointments, we strongly encourage parents to schedule these appointments after school. ______________________________ Parents Name (Please Print) ______________________________ Parents Signature __________ Date Students Name (Please Print) ______________________________ Students Signature __________ Date