REQUIRED FORMS

Kindergarten ___ Release of Medication (if applicable)

___ Daycare sign-up (if applicable)
___ Immunization form ___ Athletic Participation/Emergency
___ Health Appraisal form forms (if applicable)
(signed by doctor) ___ Band sign-up (if applicable)
___ Copy of birth certificate
___ Emergency Contact form 5th grade
___ Transportation Policy and Agreements
___ Permission to Publish ___ Health appraisal form
___ Emergency Treatment/Medical (signed by doctor)
Information ___ Emergency Contact form
___ ID Information ___ Emergency Treatment/Medical
___ Waiver/Indemnity form Information
___ Film Permission ___ Transportation Policy and Agreements
___ Handbook “Read and Accept” form ___ Permission to Publish
___ Release of Medication (if applicable) ___ ID Information
___ Daycare sign-up (if applicable) ___ Waiver/Indemnity form
___ Film Permission
1st-3rd grade ___ Handbook “Read and Accept” form
___ Emergency Contact form ___ Release of Medication (if applicable)
___ Emergency Treatment/Medical ___ Daycare sign-up (if applicable)
Information ___ Athletic Participation/Emergency
___ Transportation Policy and Agreements forms (if applicable)
___ Permission to Publish ___ Band sign-up (if applicable)
___ ID Information 6th-8th grades
___ Waiver/Indemnity form
___ Film Permission ___ PE/Athletic Health form
___ Handbook “Read and Accept” form ___ Emergency Contact form
___ Release of Medication (if applicable) ___ Updated Immunization form (7th grade)
___ Daycare sign-up (if applicable) ___ Emergency Treatment/Medical
Information
4th grade ___ Transportation Policy and Agreements
___ Emergency Contact form ___ Permission to Publish
___ Emergency Treatment/Medical ___ ID Information
Information ___ Waiver/Indemnity form
___ Transportation Policy and Agreements ___ Film Permission
___ Permission to Publish ___ Handbook “Read and Accept” form
___ ID Information ___ Release of Medication (if applicable)
___ Waiver/Indemnity form ___ Daycare sign-up (if applicable)
___ Film Permission ___ Athletic Participation/Emergency
___ Handbook “Read and Accept” form forms (if applicable)
___ Band sign-up (if applicable)
 EMERGENCY CONTACT FORM
REDEEMER LUTHERAN SCHOOL—2010/2011

LAST NAME _____________________________ HOME PHONE ________________

CHILD NAME _____________________________ GRADE _________

CHILD NAME _____________________________ GRADE _________

CHILD NAME _____________________________ GRADE _________

FATHER _________________________________ OCCUPATION ________________________________

EMPLOYER ______________________________ TITLE _______________________________________

WORK PHONE ___________________________ CELL PHONE _________________________________

PAGER _________________________________ EMAIL ADDRESS _____________________________

MOTHER _______________________________ OCCUPATION ________________________________

EMPLOYER _____________________________ TITLE _______________________________________

WORK PHONE __________________________ CELL PHONE _________________________________

PAGER ________________________________ 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: Please contact the school office if someone
not on your authorized list will be picking up
Cell phone numbers ____Yes ____ No your child. Picture ID required.
 EMERGENCY TREATMENT/MEDICAL INFORMATION
SCHOOL YEAR 2010/2011
(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 student’s 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. _____________________________

Physician’s Name _____________________________________ Phone __________________

Address _____________________________________________________________________

Physician’s Signature __________________________________ Date _________________ __

 REDEEMER LUTHERAN SCHOOL
BUILDING CARING AND SHARING DISCIPLES

2010-2011 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 sei-
zures), 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 sepa-
rate 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 admo-
nition 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 sig-
nature 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 School—2010/2011
____________________________________________________

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 School—2010/2011
____________________________________________________

Name _____________________________________________________________

Height _______ Weight __________

Address ____________________________________________________________

City _____________________ State ______ Zip ________ Phone ____________

Insurance Name and ID Number __________________________________________

Nearest Relative _______________________________________________________

Address ____________________________________________________________

City _____________________ State ______ Zip ________ Phone ____________

Medical Information _____________________________________________________

Allergic Information _____________________________________________________

 PE AND ATHLETICS HEALTH FORM
Redeemer Lutheran School—2010/2011
____________________________________________________________

Last Name ________________________ First Name ______________________

Date of last physical exam ____________ Date of Birth _____________________

Since his/her last physical exam, has the student: (circle number of any “yes” categories)

(1) Has surgery

(2) Been hospitalized
(3) Been under a physician’s care for health care problem(s)
(4) Had a serious illness
(5) Had an injury requiring physician’s care
(6) Had an episode of unconsciousness
(7) Experienced dizzy spells of blackouts
(8) Started taking any new medications-prescriptions or over-the-counter
(9) Developed any new drug allergies
(10) Had any episodes of unexplained shortness of breath, wheezing or chest pain
(11) Developed any new health problems
(12) 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 School—2010/2011

_________________________________________________________________

Parental Release For Administration of Medication to Pupils

(Signed and returned only if your child needs to have medication dur-
Also, please fill out if your child will
ing the school day)
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 ___________________

Medication Dosage Information

(must have physician signature if prescription medication)

Physician prescribing medicine ____________________________________________

Telephone number _____________________________________________________

Approximate time medication should be administered __________________________

Dosage _________________ Type of medication ___________________________

 PLEASE FILL OUT BOTH SIDES OF THIS FORM!

SPORTS EMERGENCY INFORMATION FORM

Redeemer Lutheran School—2010/2011
____________________________________________________________

Name _______________________________________________ Boy _________ Girl __________

Address _________________________________________________________________________

Age ________ Birthdate _____________________ Weight ___________ Height ___________

Child’s 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 spe-
cific 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 it’s contests if he/she so de-
sires 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 player’s parent or relative, coach, or other staff person.

______ I will help others with transportation whenever possible.

______ I understand that if my child’s 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 Par-
ent Handbook—Page 8) for extra curricular activities. We will abide by both of these out-
lines.

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: _________________________ Drivers Name: __________________________

Utah Driver’s License # ___________________ Utah Driver’s License # __________________

Expiration Date: _________________________ 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. Re-
deemer 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 chil-
dren 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.

 BAND SIGN-UP FORM
These are the most commonly played band instruments that will be allowed in band this year:
FLUTE CLARINET ALTO SAXOPHONE TENOR SAXOPHONE
TRUMPET TROMBONE BARITONE HORN
ELECTRIC BASS PERCUSSION (GLOCKENSPIEL)

Less commonly played instruments that also are allowed:

OBOE BASSOON E flat ALTO SAXOPHONE B flat BASS CLARINET
E flat BARITONE SAXOPHONE TUBA F HORN

STUDENT ______________________________________________________

ADDRESS _______________________________________ ZIP _________________

TELEPHONE # _________________________________________________

GRADE THAT YOU WILL BE ENTERING__________________________________________

INSTRUMENT THAT YOU WOULD LIKE TO PLAY _________________________________

BAND FEES—for 2010-11, $400 for the entire year, $360 if paid in full by October 15th. That includes
two rehearsals per week, plus at least three concerts throughout the year. Monthly payments would be
$45/month, due on the first band period of the month.

BAND SIGN-UP FORM

These are the most commonly played band instruments that will be allowed in band this year:
FLUTE CLARINET ALTO SAXOPHONE TENOR SAXOPHONE
TRUMPET TROMBONE BARITONE HORN
ELECTRIC BASS PERCUSSION (GLOCKENSPIEL)

Less commonly played instruments that also are allowed:

OBOE BASSOON E flat ALTO SAXOPHONE B flat BASS CLARINET
E flat BARITONE SAXOPHONE TUBA F HORN

STUDENT ______________________________________________________

ADDRESS _______________________________________ ZIP _________________

TELEPHONE # _________________________________________________

GRADE THAT YOU WILL BE ENTERING__________________________________________

INSTRUMENT THAT YOU WOULD LIKE TO PLAY _________________________________

BAND FEES—for 2010-11, $400 for the entire year, $360 if paid in full by October 15th. That includes
two rehearsals per week, plus at least three concerts throughout the year. Monthly payments would be
$45/month, due on the first band period of the month.
 Student Permission to Publish
2010-2011

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 un-
derstand the above will only be used for activities related to Redeemer Lutheran School.

Student’s Printed Name _________________________________________

Student’s 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.

Parent’s Printed Name _________________________________

Parent’s 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 valu-
able resource. To that end, our goal is to provide quality childcare that is nurturing, depend-
able, 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 7:15 a.m. each morning. Children
who arrive between 7:15-8:00 a.m. must report to the posted before school care classroom.
The charge for Before School Care is $4.00.
 REDEEMER LUTHERAN SCHOOL
AFTER SCHOOL CARE
SIGN-UP

Student Name ______________________________________ Grade ___________

Student Name ______________________________________ Grade ___________

Student Name ______________________________________ Grade ___________

Method of Payment ______ $4.00/hour

(Check one) ______ $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 2010-2011

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 authori-
zation 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 __________