Microsoft word - permission and releases.doc

Special Needs Schools of Gwinnett, Inc
Permissions & Releases Form
We would like to welcome you and your child to Special Needs Schools of Gwinnett, Inc. (SNS). Please read over the following releases, initial each one on the line provided beside each one, and sign and date at the bottom of the page. Accident Policy
_____ Although I understand that Special Needs Schools of Gwinnett, Inc. is fully insured and that the staff will do everything in their power to insure that my child is taken care of; I also realize that accidents may happen. I hereby release SNS from responsibility for accidents or injuries to my child. If an emergency or accident occurs, I hereby grant permission for the SNS staff to take whatever steps may be reasonably necessary to obtain emergency medical care for my child. As all SNS staff members are 1st Aid and CPR Certified, minor injuries will be treated at school. An incident report will be filled out and the parent or guardian will be notified by phone, by writing and/or in person. If the injury is of a more serious nature, the following steps may be taken (but are not limited to): Attempt to contact a parent or guardian with information provided on the child’s emergency on file (This includes all emergency contact numbers and people listed). Attempt to contact the child’s physician. And in the event that the above attempts are unsuccessful, we will in a speedy and timely manner; and/or have the child taken to the nearest emergency room or hospital. I understand that any expenses incurred under #3 are my sole responsibility. Records Release
_____ Special Needs Schools of Gwinnett, Inc. has my permission to obtain and release records or verbal information concerning my child for the purpose of meeting his/her educational and/or therapeutic needs. Photographs / Publicity
_____ I grant permission for my child to be included in photographs, slides, news articles and/or videos connected with publicity for SNS and/or with educational purpose. Field Trips
_____ I understand that students at SNS have the opportunity to go on field trips for educational and/or
therapeutic purposes. When on a field trip, I understand that my child will be under the supervision of SNS
staff and will be traveling in fully insured vehicles (either our school van, staff vehicles or other private
vehicles). I hereby release the SNS staff and SNS chaperones of any responsibility for accidents that might
occur. I understand that I will receive written information concerning each field trip and will be asked to give
written permission for my child to attend. I understand that it is my responsibility to keep my child’s
records of emergency contact information current and up to date.

Medication Permission
_____ I hereby give permission for the SNS staff to administer to my child (after contacting me), should it become necessary Children’s Tylenol or Motrin (or generic equivalent) to reduce fever or pain as well as Benedryl (or generic equivalent) to relieve allergic reactions my child may experience while at school and under the care of SNS staff members. If my child is allergic to any of the above, then medications will be provided by me and kept at school with my child’s name clearly marked on the original bottle /package. I understand that all other medications my child is prescribed to take during the school day will need a completed “medication form” filled out in advance and accompanied by the original prescription bottle/container from the doctor/pharmacy indicating the proper dosage and time. Child’s Name:_________________________________________ Age;______ Weight:_______ Parent or Guardian Signature:_____________________________________ Date:___________ Parent or Guardian Signature:_____________________________________ Date:___________

Source: http://www.specialneedsschools.org/pdf/Permission_Releases.pdf