LC Permissions and Other Information Form
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Student Name *
Has your address changed from the previous school year (if previously enrolled?) *
Primary Home Address *
Primary Home Telephone *
Parent #1 Name *
Parent #1 E-mail *
Parent #1 Cell Phone *
Parent #1 Home Address
Only list if different from primary address listed above
Parent #2 Name
Parent #2 Email
Parent #2 Cell Phone
Parent #2 Home Address
Only list if different from primary address listed above
Physical Activities - We agree to give our permission to have our child participate in physical activities that would take place at Little Creek *
Photo Release - We agree to give our permission to have our child's picture in school publicity that would include:  brochures, Facebook, and other promotional material utilizing Radcliffe Creek Students as approved by the School Administration *
Transportation - We agree to give our permission for Little Creek staff and/or volunteers to transport our child in their own vehicles WITH prior notifcation *
Medication - We agree to give our permission for a Trained and Certified Medication Assistant to administer medicines as ordered by my child's physician per the MEDICATION AUTHORIZATION FORM (separate document that must be printed out). ALL medications (both over-the-counter and prescribed) must be provided by the parents in their ORIGINAL containers and LABELED *
Name of Student's Medical Insurance Plan *
Address of the Plan *
Name of the Insurance cardholder *
Relationship to student *
Membership or Policy Number *
Parent #1 Parent Names (student's grandparents)
Address
City
State
Zip
Parent #2 Parent's Names (student's grandparents)
Address
City
State
Zip
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