CONTACT INFORMATION FORM This form will remain on file until you submit updated information.
Date:
STUDENT INFORMATION Student 1:
Student 2:
Student 3:
Student 4:
INSURANCE INFORMATION Insurance Company:
Group #:
Name of policyholder:
Policy #:
☐ I do not have an insurance provider at this time LEGAL DOCUMENTS: (Restraining order, Custody Agreements and any other court documents) ☐ YES – Please provide documents ☐ NO PARENT/GUARDIAN INFORMATION
Father:
Cell Phone:
Email:
Home Phone:
Address:
Street
City
State
Lives with student: ☐ Yes ☐ No
Zip
Mother:
Cell Phone:
Email:
Home Phone:
Address:
Street
City
State
Lives with student: ☐ Yes ☐ No
Zip
EMERGENCY CONTACT INFORMATION | Please list at least two persons not listed above. Any person listed may be contacted in an emergency; parent/guardian contact will be attempted first. Any person listed may pick student up from school. Lives with Student
Name
Relation
Home #
Cell #
Work #
Name
Relation
Home #
Cell #
Work #
☐ Yes ☐ No Lives with Student
☐ Yes ☐ No Lives with Student
Name
Relation
Home #
Cell #
Work #
☐ Yes ☐ No
STUDENT INFORMATION Student Name:
Date:
Parent permission for school trips: I hereby give permission for my student to take part in field trips and other school sponsored activities included in the planned program of the school. Transportation may be provided at the discretion of Western Mennonite School in such form as approved. ☐ YES
☐ NO
Do you have any reason to believe your child is not physically able to take part in all school-sponsored activities he/she chooses? ☐ YES
☐ NO
If yes, please explain:
Is there anything unique related to your child’s physical condition or medical history which the school should know? ☐ YES
☐ NO
If yes, please explain:
Please list known allergies:
I authorize Western Mennonite School, its employees and my child’s weekend/hospitality home (if applicable) to administer first aid or secure the services of a physician or hospital, and to incur expenses for necessary services in the event of accident or illness. I will be responsible for any medical bills accrued by my child while attending Western Mennonite School and will not hold Western Mennonite School responsible for those bills. Every reasonable effort will be made to contact the parent(s) as soon as possible. By signing below I confirm and agree to the selections made in the check boxes above. Parent/Guarding Name (Please Print):
Date:
Parent/Guardian Signature:
Form Required for Every Student
TRANSPORTATION PERMISSIONS Student Name:
Date:
WMS is a closed campus. All students, unless specifically approved by the student’s parent/guardian and WMS administration will not be allowed to leave campus during the school day, nor drive themselves to any athletic events. Please complete this form with your student so that they will understand the selections you have mad. This form will remain on file until the parent submits signed changes.School transportation policies can be found on page 30 of the student handbook PERMISSION AS A PASSENGER (CHECK ALL THAT APPLY): While my son/daughter is under the supervision of WMS, I give him/her permission to ride in private vehicles with the following : ☐ My son/daughter may not ride in any vehicle, outside of WMS’s standard policy, without my specific permission. ☐ Any student driving to and from school or school events. ☐ Any driver 25 years of age or older. ☐ Older siblings. ☐ Only with the following drivers:
☐ My student has permission to leave campus during Friday lunch with the following drivers:
PERMISSION AS A DRIVER (CHECK ALL THAT APPLY): WMS students are expected to obey the Oregon State driving laws and WMS driving regulations. Failure to comply with any driving regulations may result in the loss of driving permissios. ☐ My son/daughter may not drive another student in his/her car without my specific permission. ☐ I give my son/daughter permission to drive a vehicle to and from Western Mennonite School and/or school sponsored events. ☐ My son/daughter may transport younger siblings. ☐ My son/daughter may transport other Western Mennonite School students, provided the passenger has riding permission. ☐ My son/daughter may transport only the following WMS students, provided the passenger has riding permission.
☐ My student has permission to leave campus during Friday lunch with the following passengers:
VEHICLE REGISTRATION
Please register any vehicle(s) that you will be driving to campus this school year. VEHICLE #1
VEHICLE #2
Color:
Make:
Color:
Make:
Model:
License:
Model:
License:
Parent/Guardian Signature:
Date:
Student Signature
Date:
MEDIA CONSENT & COMMUNICATION PREFRENCES MEDIA CONSENT AND RELEASE: Student Name(s):
Date:
Students at WMS are occasionally asked to be a part of school publicity, publications, and public relations materials and programs (including but not limited to print, web and video). In order to guarantee student privacy, Western Mennonite School requires parent/guardian authorization permitting its use of student information. By signing below, I give Western Mennonite School permission to use information about my student in school publicity, publications, and videos or on the school’s website. Information includes, but is not limited to, student’s name, picture, art projects, written work, voice, verbal statements or portraits (video or still). I understand that this information may be used in subsequent years. Parent/Guardian Signature: Hometown Newspaper: If you do not want WMS to use student information in specific areas, please indicate what you do not authorize below:
STUDENT DIRECTORY NOTICE REGARDING DIRECTORY INFORMATION: I hereby give consent for the student’s grade level and parent’s address and phone number to be listed in the school directory. ☐ YES ☐ NO (If NO, please send a written request to the school)
ALERT SOLUTIONS Alert Solutions is a communication tool through Powerschool. It is used to alert you in emergency situations, inform you of delays or schedule changes, attendance, athletic information, event details, and fundraising opportunities. Western Mennonite School has permission to contact us via: ☐ Phone Calls
☐ Text Messages
☐ Emails
☐ Permission denied
For the following types of messages (Emergency calls will be made regardless of preferences selected here): ☐ Messages which can include school activity reminders, notices, general school information, e ☐ Messages which can include fundraising events or notice Using the following contacts: Name:
Name:
Home #:
Email 1:
Cell #:
Email 2:
Home #:
Email 1:
Cell #:
Email 2:
Parent/Guardian 1 Signature:
Date:
Parent/Guardian 2 Signature:
Date:
Auto Pay Authorization I hereby authorize Western Mennonite School to charge my bank account monthly for the purposes designated below. My bank is authorized to handle withdrawals on the of each month or the next banking day as if I had personally issued a check. I will undertake to promptly notify Western Mennonite School, in writing, of any change in the account information provided in this authorization. Authorization will remain in effect until notification to terminate or limit is given in writing or by email. Personal Information Last Name:
First Name:
Phone Number:
Email:
Mailing Address:
City
Middle Initial:
State
Zip Code
Bank Information (Attach a voided check –OR– fill in information below) Account Type:
Name: Bank Address:
City
Routing Number:
☐ Checking ☐ Savings
State
Zip code
Account Number:
☐ Monthly tuition/fees withdrawal (Amount may vary)
☐ Monthly Donations Amount: $
☐ No changes from what is currently on file Authorized Signatures X
X
Signature of Bank Account Holder
Signature of Bank Account Holder
Date:
Date: