Student Information

This is located on your Student Contract.​​
MM/DD/YYYY​

Parent Information

Please include a first and last name.​​

Emergency Contact Information

Please provide contact information for at least one individual outside your immediate family.

Please include a first and last name.​​
Please include a first and last name.​​

Medical Emergency Treatment Consent

I hereby give my permission for Canterbury School to obtain the services of any of the indicated physicians or hospitals in case the above named student suffers illness of accident, and the parent or guardian cannot be contacted. In case none of the above named persons can be contacted, I authorize school officials to take whatever action is considered to be in the best interest of my child.

Type your first and last name, to be used as your electronic signature.​​

Allergies, Medical Issues and Restrictions

Please list your child's restrictions, chronic medical issues or allergies. Examples include food allergies, bee sting reactions, asthma, seizures, cardiac problems and any other medical conditions that are important for the school to know.

Tylenol Permission

On occasion, a well child may require an analgesic. If you wish for this to be an option for your child during the school year, check the "Yes" button below to indicated that your child may take Tylenol in the amount recommended by the manufacturer for his/her age. By checking "Yes," you also understand that non-medically trained school personnel may administer it.

Field Study and Trip Permission

I give my permission for my child to participate in educational field studies/trips during the school day. These activities will be planned and supervised by Canterbury School faculty and staff. I understand that the Canterbury School rules and behavior expectations guidelines listed in the Parent-Student Handbook apply to student conduct during all field studies and trips.

Sunscreen Permission

I understand that too much sunlight can increase the risk of skin-related health concerns. I give Canterbury School permission to supply – and apply, when appropriate – sunscreen product of SPF-15 or higher when my child is outside, especially during the months of March through October and times between 10 a.m. and 4 p.m. I understand that sunscreen may be applied to exposed skin, including but not limited to the face, tops of the ears, nose and bare shoulders, arms, and legs.

Should I choose not to give Canterbury School permission to supply – and apply, when appropriate – sunscreen product of SPF-15 or higher when my child is outside, I understand that I will be responsible for supplying my child's own sunscreen and applying it before school, when appropriate.


Trip Waiver, Athletic Travel Waiver, Medical Treatment and Assumption of Financial Responsibility

As the parent or legal guardian, I understand Canterbury School sponsors trips that go beyond the school day (i.e.: athletics events, class or grade level trips, travel to other cities, states or countries, etc.), and I give permission for my child to participate fully in school trips/travel.

I hereby authorize the school representatives to take my daughter/son to a physician or hospital as may be indicated under the circumstances, to authorize on my behalf any medical treatment recommended for my daughter/son by an attending physician, including emergency treatment and surgery, and to assume on my behalf full financial responsibility for all medical bills incurred for such medical care and treatment rendered thereafter. I understand that an attending physician, or hospital, may require verbal permission from me over the telephone before medical care or treatment can be rendered to my daughter/son.

I hereby agree to assume full financial responsibility for all transportation costs, and to reimburse the school for all such costs paid, if it becomes necessary for my daughter/son to return home for any reason, including illness or injury requiring medical care or treatment, or for disciplinary reasons.

Additionally, for my student athlete, I give permission to the attending sports medicine personnel (certified athletic trainer, team physician or team physical therapist, etc.) to provide onsite evaluation and treatment. The attending sports medicine personnel may discuss my athlete's medical status with the coaching personnel


Parent/Guardian Electronic Signature

Type your first and last name, to be used as your electronic signature.​​