Emergency Form - Tylenol Permission - Travel Waiver

Every Canterbury student must have emergency information on file with the school. The school collects this information annually via the following online form with includes: Emergency Info, Permission to Treat, Allergy Info, Tylenol Permission, and Day Field Studies Permission (allowing students to go on field studies during the school day), and Authorization for Medical Treatment and Assumption of Financial Responsibility (extended trips/travel and athletics travel and treatment).

Please submit the following online form by August 15, 2015. (For Fall HS Athletes, we need this form by August 1 so your child may attend August 4 practices). Failure to submit the form means your child will not be allowed to attend class or sports practice until the form is submitted. Please fill out one form per student.

The information from this form will be kept in the school offices for each student enrolled in that division. Emergency and Permission to Treat information will also be shared with the athletics offices in Middle and High School, for those students participating in school sports. 

Please note, you must fill in all *required fields in order for the form to submit  successfully. When you hit the orange SUBMIT button, a message will pop up on the screen that the form was submitted successfully. You will receive a receipt of the form (usually within 30 minutes) to the email address entered in the Primary Contact Email address field.


School Division

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. (Please type your full name in the field below to give consent.)


Please list any restrictions, chronic medical issues or allergies in the space provided below for your child. Examples include food allergies, bee sting reactions, asthma, seizures, cardiac problems and any other medical conditions that are important for the school to know. A separate prescription medication form was sent home in the August mailing and also is located in under the FORMS link if you need it during the school year.


On occasion, a well child may require an analgesic. If you wish for this to be an option for your child during the 2014-2015 school year, please 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.

My child may take Tylenol
FIELD STUDY/TRIP PERMISSION (during the school day)

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 apply to student conduct during all field studies and trips.

My child has permission to attend field studies/trips during the school day.
Trips and Athletics Travel Waiver and Medical Treatment and Assumption of Financial Responsibility

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

I agree with the information presented above regarding Trips/Athletics and Travel, Medical Treatment and Assumption of Financial Responsibility.
Parent or Guardian Electronic Signature

My electronic signature signifies that the information provided in this document is accurate and that I have provided information, consent, authorization or agreement where indicated.

Please double check all contact info is correct. If it is not please take this time to make changes. When you are ready hit the orange SUBMIT button.