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Student Contact Information

Parent #1 Contact Information

Parent #2 Contact Information

Emergency Contact Information

Emergency Contact Information

Off Campus Travel

My student has permission to go off campus, after obtaining appropriate permission, with the following persons:

Verbal Permissions

Selecting "yes" for the following options will allow you to give verbal permission over the phone. I wish to be able to give verbal/phone permission for my student to be able to:

Medical Information

Please note that we will not allow students to self-administer medications

Consent to Treatment

I, the undersigned parent or guardian of the above minor, do hereby consent to any X-ray examination, immunization, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be required to aid minor under the general or specific instruction of any physician the school or organization may call, whether such diagnosis or treatment is rendered at the office of said physician or at a licensed hospital. It is further understood that this consent is given in advance of any specific diagnosis or treatment which might be required and is given to authorize Dakota Adventist Academy or the physician to exercise their best judgment as to the requirements of such diagnosis or treatment. I hereby authorize any hospital physician, or other person who has attended or examined the minor to furnish the insurance service, or its representative, any and all information with respect to any illness, medical history, consultation, prescription or treatment, and copies of all hospital or medical records. A copy of this authorization shall be considered as effective and valid as the original. I, the undersigned parent or guardian of the above minor, hereby authorize the school nurse/dean/EMT of Dakota Adventist Academy to give over-the-counter medications in the event of minor illnesses and/or injuries such as headaches, colds, sore muscles, etc. All over-the-counter medication will be checked for compatibility with any prescription medication that your child may be taking. Please notify the school nurse of the medications your child is taking. If the condition persists, a medical evaluation will be obtained.

Education Information

List all schools attended fromt eh 8th grade to the current year. Include online or correspondence classes

Residence Information

If needing host family for breaks, please answer the following questions.



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