* Required

2022-23 Emergency Form

Please complete one form per student.

Information provided in this form will be maintained in school offices for every enrolled student. Emergency and Permission to Treat information will also be shared with the Middle and High School Athletics Offices, for students participating in sports.

Please note: You must complete all required fields in order to successfully submit the form. When you hit the "Submit" button, an on-screen message will appear, indicating the form was submitted successfully. You will receive a receipt of the form (usually within 30 minutes) to the email address you provided.

Student Information


Parent Information

Emergency Contact Information

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

Please provide the order of which emergency contact to contact 1st, 2nd, 3rd, etc. ​you would like us to contact if we are unable to reach you. ​

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

CHIRP Consent

Canterbury School has permission to release the following information concerning my child to the Indiana State Department of Health's Children and Hoosiers Immunization Registry Program (CHIRP).

Information that will be released: name, immunization data, date of birth, address, phone number and ethnicity.

I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me of my child's immunization status or that an immunization status or that an immunization is due according to recommended immunization schedules.

I understand that my child's information will be available to the immunization registry of another state, a health care provider, a local health department, an elementary or secondary school that is attend by the individual, a child care center, and the office of Medicaid Policy and Planning or a contractor of the office of Medicaid Policy and Planning. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3.

Medical Emergency Treatment Consent

As stated in your continuous enrollment contract, you have agreed to the following information:

"Medical Authorization: If, in the opinion of a properly licensed and practicing physician, Student needs medical or surgical services which require Parent's pre-authorization or consent, Parent hereby authorizes, appoints, and empowers the School to act as Parent and furnish such consent on Parent's behalf. Parent confirms that it is Parent's desire that Student be furnished with such medical or surgical services as soon as reasonably possible after the need arises. Parent hereby releases and holds School harmless from any liability which might arise from the giving of such consent. Parent agrees to reimburse the School for any medical expenditures made on Student's behalf.

"Consent to On Site Medical Care, Including Student Counseling: The Parent hereby authorizes the School to supply medical care as needed fro Student (including administration of allergy medications, Epy-Pens, etc. according to the Student's prescription from a licensed practitioner) or other minor medical care as determined to be appropriate by the School Clinic Coordinator and/or Nurse. The Parent also authorizes the School's student guidance counselor to meet and and counsel with Student regarding emotional, social, or family circumstances. Parent hereby releases and holds the School harmless from any liability which might arise from provision of such medical care or counseling services."

Parent/Guardian Electronic Signature

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