information update form 2014-2015 part 1

INFORMATION UPDATE FORM 2014-2015
PART 1
All families are asked to update this form every year.
Please complete all the missing information.
STUDENT’ S INFORMATION
Last/First/Gender:
Street Address:
City/State/Zip:
City:
State:
Zip:
Home Phone:
Birth Information:
DOB:
Country:
City:
State:
PARENT 1 / GUARDIAN INFORMATION
Last/First:
* Full address if diff.:
* Home Phone if diff.:
Work/Cell Phone:
Bus.:
Cell:
E-mail:
PARENT 2 / GUARDIAN INFORMATION
Last/First:
* Full address if diff.:
* Home phone if diff.:
Work/Cell Phone:
Bus.:
Cell:
E-mail:
PARENT 3 / GUARDIAN INFORMATION
Last/First:
* Full address if diff.:
* Home phone if diff.:
Work /Cell Phone:
Bus.:
Cell:
E-mail:
PARENT 4 / GUARDIAN INFORMATION
Last/First:
* Address if diff.:
* Home phone if diff.:
Work/Cell Phone:
Bus.:
Cell:
Email:
* See enclosed letter.
Confidential
6/24/2014
©Ecole Bilingue
INFORMATION UPDATE FORM 2014-2015
PART 3 – PARENTS’ PROFESSIONAL INFORMATION
All families are asked to update this form every year. Please complete all the missing information.
STUDENT’S INFORMATION
Last / First
PARENT 1 / GUARDIAN INFORMATION
Last/First:
Business name:
Matching gift:
Yes
No
Business address:
City/State/Zip:
Business phone:
Position/Profession
Board affiliation:
PARENT 2 / GUARDIAN INFORMATION
Last/First:
Business name:
Matching gift:
Yes
No
Business address:
City/State/Zip:
Business phone:
Position/Profession
Board affiliation:
PARENT 3 / GUARDIAN INFORMATION
Last/First:
Business name:
Matching gift:
Yes
No
Business address:
City/State/Zip:
Business phone:
Position/Profession
Board affiliation:
PARENT 4 / GUARDIAN INFORMATION
Last/First:
Business name:
Matching gift:
Yes
No
Business address:
City/State/Zip:
Business phone:
Position/Profession
Board affiliation:
Confidential
7/8/2014
©Ecole Bilingue
INFORMATION UPDATE FORM 2014-2015
PART 2 - GRANDPARENTS
All families are asked to update this form every year. Please correct any inaccurate information and complete all the missing fields.
Information on grandparents allows us to send appropriate invitations, communications and solicitations.
STUDENT’S INFORMATION
Last / First name /
Graduation year:
Graduation Year:
GRANDPARENT 1
Name:
Full address:
Phone / Email:
GRANDPARENT 2
Name:
Full address:
Phone / Email:
Phone:
Email:
GRANDPARENT 3
Name:
Full address:
Phone / Email:
Phone:
Email:
GRANDPARENT 4
Name:
Full address:
Phone / Email:
Phone:
Email:
GRANDPARENT 5
Name:
Full address:
Phone / Email:
Confidential
Phone:
Email:
Page 1
7/8/2014
©Ecole Bilingue
EMERGENCY MEDICAL FORM 2014-2015
Décharge médicale 2014-2015
There may be circumstances during the regular operation of the school and Extended Day, and/or during
natural disasters where the school would not be able to contact a parent or legal guardian to obtain permission to
administer medical or dental care. Please read and sign the form below to allow such care in these emergency
situations.
As the parent or guardian of ________________________________ I hereby give consent to Ecole
Bilingue de Berkeley to provide all emergency dental or medical care prescribed by a duly licensed physician
or dentist for my child(ren). This care may be given under whatever conditions are necessary to preserve
the life, limb or well-being of my child.
En cas d’urgence, j’autorise l’Ecole Bilingue de Berkeley à prendre les mesures nécessaires pour tous soins dentaires ou médicaux
dûmont prescrits par un dentiste ou un médecin. Ces soins peuvent être donnés pour preserver la vie, un membre ou le bien-être de
mon enfant.
Signature of Parent or Guardian
Signature du Parent ou Tuteur
Date
Date
Please print names of all parents and/or guardians below:
______________________________________
_________________________________________
______________________________________
_________________________________________
Please provide us with CURRENT MEDICAL CONDITIONS or ALLERGIES for your child. (Please contact
the school during the year with any updated changes to your child’s medical conditions).
____________________________________________________________________________________
____________________________________________________________________________________
Family Physician & Phone _______________________________________________________________
____________________________________________________________________________________
********************************************************** ****
In the event of an emergency, it may be necessary to evacuate the campus. Please list below the names
of individuals to whom the school can release your child in the event a parent or guardian is not able to
come to campus. This list may be modified at any time.
Name:
Home Phone:
Cell Phone:
1. ____________________________
____________________________________________________
2. ____________________________
____________________________________________________
3. ____________________________
____________________________________________________
4. ____________________________
____________________________________________________
ACTIVITY PERMISSION, ASSUMPTION OF RISK AND RELEASE
The undersigned parent/guardian(s) (“Parent”) of __________________________ (“Student”)
permits Student to attend and participate in all Ecole Bilingue de Berkeley (“School”) activities,
events, off-campus travel/transportation, field trips, sporting events and other school-sponsored
activities, some of which involve a heightened risk of injury.
Parent understands that there are inherent risks of serious bodily injury and property damage
involved in all of the above activities and travel. On behalf of Student, Parent voluntarily assumes
and accepts such risks of personal injury and property damage arising from Student's attendance and
participation in such activities and travel, and agrees to assume financial responsibility for emergency
care and services for Student, including rescue and transportation services, if not covered by the
School’s student accident insurance.
This express assumption of risk and release do not apply to liability for gross negligence or
intentional injury, and are not intended to apply to School’s insurer or non-agent third parties.
This consent shall continue in effect from year to year as long as Student is a student of the School,
unless the undersigned subsequently notifies the Assistant Head of School in writing that this ongoing authorization has been terminated.
_______________________________________
Parent/Guardian Name (please print)
_______________________________________
Parent/Guardian Signature
_________________________
Date
DEMOGRAPHIC INFORMATION
For all families new to EB
All families are asked to complete this form when they enroll at
EB. See specific directions on the back of this form
STUDENT’ S DEMOGRAPHIC INFORMATION
Last / First Name(s):
Birth country:
Ethnicity:
French / US citizen:
Other Nationality/ies:
Language spoken at home:
French:
Nationality 1:
French:
Yes
Yes
No
US:
No
English:
Yes
No
Yes
No
Nationality 2:
Other languages:
PARENT 1 / GUARDIAN INFORMATION
Last / First:
Birth country:
Ethnicity:
French / US citizen:
Other Nationality/ies:
French:
Nationality 1:
Yes
No
US:
Yes
No
Nationality 2:
First Language:
Language spoken at home if
diff.:
PARENT 2 / GUARDIAN INFORMATION
Last / First:
Birth country:
Ethnicity:
French / US citizen:
Other Nationality/ies:
French:
Nationality 1:
Yes
No
US:
Yes
No
Nationality 2:
Language spoken at home if
diff.:
PARENT 3 / GUARDIAN INFORMATION
Last / First:
Birth country:
Ethnicity:
French / US Citizenship:
Other Nationality/ies:
French:
Nationality 1:
Yes
No
US:
Yes
No
Nationality 2:
First Language:
Language spoken at home if
diff.:
PARENT 4 / GUARDIAN INFORMATION
Last / First:
Birth country:
Ethnicity:
French / US Citizenship:
Other Nationality/ies:
First Language:
Language spoken at home if
diff.:
French:
Nationality 1:
Yes
No
US:
Nationality 2:
Yes
No
Dear Families New to EB,
The form on the back of this letter is to collect demographic information necessary for
various governmental and accrediting organizations. We request this information once
families have enrolled. The specific directions are below:
1. Under Student and Parent/Guardian “Ethnicity,” please use one of the entries listed
below. These are the guidelines and categories for self-reporting ethnicity provided to
all member schools from the National Association of Independent Schools.
•
•
•
•
•
•
•
•
•
African American
American Indian or Alaska Native
Asian American
Asian or Pacific Islander
Caucasian (European American)
Hispanic American
International [(If you are not a US citizen or permanent resident
(green card holder), please select this category regardless of ethnicity].
Middle Eastern American
Multiracial (People who identify with more than one ethnic race
heritage and are US citizen or permanent resident of the United
States)
2. The category “Other Nationalities” can be used for other nationalities than French or
U.S. citizens and also for French and /or U.S. citizens that have another nationality/ies
by virtue of their parents’ citizenship.
Thank you so much for helping us collect this information. If you have any questions, please
contact the Lower School office for assistance.
EXAMEN MEDICAL 2014-2015
PHYSICIAN’S REPORT OF MEDICAL EXAMINATION 2014-2015
4th and 7th Grades only / CM1 et 5ème seulement
J’autorise l’envoi des informations médicales ci-dessous à l’Ecole Bilingue de Berkeley:
I hereby give my consent for the release of medical information to the Ecole Bilingue de Berkeley:
Nom de l’enfant:
Prénom de l’enfant:
Niveau:
Child’s last name:
Child’s first name:
Grade:
Adresse:
Address:
Street/ rue
Téléphone:
Telephone:
Signature du parent ou tuteur:
Signature of parent or guardian:
City/ ville
Date de naissance:
Birthdate:
Date:
Date:
Zip/ code postal
To be completed by the physician/ A remplir par le médecin
L’état de santé de l’enfant peut-il constituer un cas d’urgence en classe?
Are there any medical conditions that might result in a classroom emergency?
Y a-t-il des activités interdites à l’enfant ?(éducation physique, autres…)
Are there any restrictions on regular physical education and activity?
Les vaccinations recommandées sont-elles à jour?
Are recommended immunizations up-to-date?
Yes/ Oui
No/ Non
Date de: dernier rappel antitétanique:
dernier test tuberculinique:
positif
négatif
Date of: last tetanus booster:
latest TB test:
positive
dernier vaccin contre l’hépatite B
last Hepatitis B shot
7th grade only - Tdap (Tdap, Adacel, Boostrix, DTaP or DTP): ____________
Résultats des derniers examens de:
Findings of latest tests:
Vision/V ision: Right/Droite
Left/Gauche
Hearing/Ouïe: Right/Droite
Left/Gauche
Additional comments/ Autres remarques:
negative
Mon examen ne met en évidence aucune autre condition qui puisse empêcher l’enfant de suivre une scolarité normale.
My examination reveals no other conditions relevant to the school program.
Signature of physician
Signature du médecin
Print name
Nom en lettres d’imprimerie
Date
Date