Mount Zion Albany GA - CAPS Tutorial App

STUDENT INFORMATION

First Name / Middle Initial

Last Name

Street Address

Street Address 2 (Type NA if not applicable)

City

State

Zip/Postal Code

Age

Grade

Home Phone

Emergency Phone

School Information

"Choose level from drop down menu"

Reading Level

Math Level

School

Area(s) of Weakness

Parent/Guardian Information

Parent First Name / Parent Middle Initial

Parent Last Name

Home Phone

Work/Emergency/Contact Phone

Parent(s) Email Address

Do you have a Gmail account?
Yes
No

Do you have Internet access?
Yes
No

EMERGENCY CONTACT FORM

Participants First Name / Middle Initial

Participants Last Name

Date of Birth:

PARENT First Name / PARENT Middle Initial

PARENT Last Name

Address

Address 2 (if not applicable type NA)

City

State

Zip/Postal Code

Enter (N/A)

Emergency Contact (1)

Emergency Contact (2)

Parent/Guardian place of employment

Employment Address/City/State

Work Phone Number

Family Doctor

Family Doctor Phone Number

Family Doctor Address/City/State

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital by car or ambulance for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, transport my child to (Hospital)

MEDICATIONS:

My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage is as follows:

Please enter Names of medications and concise directions: (i.e. Medication Name, Dosage and Frequency)

Check All that Apply:
No medication of any type whether prescription or nonprescription may be administered to my child.
No medication of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required.
I hereby grant permission for nonprescription medication to be given to my child if they become ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea such as aspirin, throat lozenges, and cough syrup.

Special Medical Information: Allergic reactions (medications, foods, plants, insects, etc.):

Vaccinations/Shots are up to date:
Yes
No

Most recent date of Tetanus Shot [ENTER YEAR]:

You should be aware of these known medical conditions of my child.

**This line below serves as an electronic signature**

DO YOU AGREE THAT THIS INFORMATION IS CORRECT? (please type yes):

All information Must Be Current

Do we have permission to photograph your child for posting and advertising?

C.A.P.S. Tutorial Application 2023