Fillable ELEMENTARY-MIDDLE SCHOOL REMOTE LEARNING CENTER STUDENT ENROLLMENT APPLICATION (Georgia Piedmont Technical College)

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ELEMENTARY-MIDDLE SCHOOL REMOTE LEARNING CENTER STUDENT ENROLLMENT APPLICATION (Georgia Piedmont Technical College)

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The ELEMENTARY-MIDDLE SCHOOL REMOTE LEARNING CENTER STUDENT ENROLLMENT APPLICATION (Georgia Piedmont Technical College) form is 2 pages long and contains:

  • 2 signatures
  • 6 check-boxes
  • 72 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Georgia Piedmont Technical College

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PREFERRED LOCATION
DeKalb/Clarkston
Newton/Covington
South DeKalb/Decatur
STUDENT INFORMATION
Child's Name:
First ___________________________ Middle ___________________________ Last ___________________________
Preferred or Nickname ____________________
Date of Birth ____________________________ Age _____
Where is your child currently enrolled in school? ___________________________________________________
(county and name of school)
Grade level
PARENT/GUARDIAN
Mother's/Guardian's Information:
First Name ___________________________ Last Name ___________________________
Address _______________________________ City ______________________ ST ___ Zip ________
Primary Phone # ________________ Alternate Phone # ________________
Email Address ____________________________________ Driver's License # _________________
Father's/Guardian's Information:
First Name ___________________________ Last Name ___________________________
Address _______________________________ City ______________________ ST ___ Zip ________
Primary Phone # ________________ Alternate Phone # ______________
__
Email Address ____________________________________ Driver's License # _________________
AUTHORIZED RELEASE & EMERGENCY CONTACT INFORMATION
Your child will only be released to the person(s) signing this application and to the following emergency
contact and/or pick up person. Contacts listed below should live locally within the state, and should be
immediately available in the event of an emergency if the parents/guardians can not be reached.
Contact Name ___________________________________ Phone # ________________
Authorized to PICK UP Yes No Authorized for EMERGENCIES Yes No
Contact Name ___________________________________ Phone # ________________
Authorized to PICK UP Yes No Authorized for EMERGENCIES Yes No
Contact Name ___________________________________ Phone # ________________
Authorized to PICK UP Yes No Authorized for EMERGENCIES Yes No
MEDICAL INFORMTION
My child's doctor is ____________________________________ Phone # ________________
Address _______________________________ City ______________________ ST ___ Zip ________
My child has (please check all that apply):
___ An allergy to medicine, food, plant, animal, or insect (if yes, please explain)____________________________
___ A physical, mental, or developmental disability that requires accommodation (if yes, please explain
below)
_______________________________________________________________________________________________
___ No known allergies or conditions
ELEMENTARY-MIDDLE SCHOOL
REMOTE LEARNING CENTER
STUDENT ENROLLMENT APPLICATION
MEDICAL INFORMTION (continued)
I, _______________________________ hereby authorize Georgia Piedmont Technical College (GPTC), in the
event of an emergency, to seek medical treatment (or contact 911 if necessary) for my child________________
_______________. If GPTC is unable to contact me immediately, GPTC is authorized to ensure my child is
transported to an appropriate medical resource and GPTC shall be authorized to secure such medical
attention and care for my child as may be necessary.
I agree to assume responsibility of payment for such services and emergency treatment.
GPTC will not administer any drug or any medication without specific instructions from the physician or the
child's parent, guardian, or full-time custodian.
Emergency Protocol Procedures will be:
1. Contact parent/guardian listed
2. Contact emergency contact(s) if parent/guardian cannot be reached
3. Call emergency medical team if necessary (911- first if needed)
4. Transport child via emergency medical team to nearest hospital, or
Parent Hospital Preference_____________________________ Phone #________________
Address _______________________________ City ______________________ ST ___ Zip ________
Please read and initial the following statements:
_____ I understand that I must check my child's health every morning
prior
to leaving for the GPTC Remote
Learning Center
_____ I understand that if my child exhibits any of the following symptoms: a temperature of 100.4 degrees or
higher, congestion or runny nose, cough, shortness of breath or difficulty breathing, diarrhea, headache,
muscle pain and fatigue, sore throat, nausea or vomiting, chills, new loss of taste or smell, I
cannot
send my
child to the GPTC Remote Learning Center.
_____ I understand that if my child was in close contact-within 6 feet for 15 minutes, with or without mask-of
someone with a suspected or confirmed case of COVID-19 in the last two weeks, or of someone getting a test
or waiting for test results, I
cannot
send my child to the GPTC Remote Learning Center.
_____ I understand that if my child cannot attend for any of the reasons above, that I should notify the GPTC
Remote Learning Center.
_____ I understand that masks are required on all GPTC campuses, including Digital Learning Centers
_____ I understand that my child must bring their own lunch, and technology (laptop/Chromebook and
charger, headphones), and must be able to perform basic functions such as powering on, connecting to the
Internet, browsing to their school's remote learning site.
_____ I understand that I (or the emergency contacts listed) may be contacted if my child exhibits any
disciplinary issues. Disciplinary issues may result in your child being dismissed from the GPTC Remote
Learning Center for the day.
_____ I understand that my child must be picked up no later than 3:30 pm. I will be assessed $1.00 per
minute for late pick ups.
________________________
Parent/Guardian Signature
________________________
GPTC Employee Signature
________________
Date
________________
Date
or
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ELEMENTARY-MIDDLE SCHOOL REMOTE LEARNING CENTER STUDENT ENROLLMENT APPLICATION (Georgia Piedmont Technical College)

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Completed 3 February 2021

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