Does your child have any current medical concerns? Yes No

My child has the following medical concern(s). Please check all that apply. ADD / ADHD* Asthma* Bleeding Disorder * Specify:* Cardiac Condition * Specify:* Diabetes* Type 1* Type 2* Eating Disorder * Specify:* Eye/Ear Problem* Specify:* Food Allergies * Specify:* Insect Allergy * Specify:* Medication Allergy * Specify:* Muscle/Bone/Joint Problem * Specify:* Recurrent Headaches* Seasonal/Environmental Allergies* Seizure Disorder* Specify:* Surgery History* Specify and Indicate Date:* Other Health Concern(s)* Specify:* My child is taking medication at Home (prescription, over-the-counter, daily or as needed).*

Specify:*

My child is taking medication at School (inhaler, Epi-pen, other).*

Specify:*

(Students who require an Epi-Pen will bring dose to office and have an emergency protocol on file)

If your child does have a medical concern, the nurse will contact you to obtain more information and to plan for the upcoming school year.

+++If any changes occur or a new condition is diagnosed during the school year, I, the parent/guardian, will notify the school nurse of the new status by providing a new student health concern form. Overnight trips might require additional forms.

Insurance Provider:* Insurance Policy Number: In case of emergency, I give permission for my child to be transported to the nearest facility and for their staff to provide the necessary treatment until I arrive. *

Release of Confidential Information: For your child's safety and well-being while at school and on field trips, it may be beneficial for appropriate school personnel to be informed of any medical conditions included on this medical authorization form. Please be assured that staff will keep this information confidential. Do you consent to sharing of medical information with school personnel? * Does this student require a physician ordered special diet?*

Please have the MEDICAL STATEMENT FOR STUDENT REQUIRING MEAL MODIFICATION form completed and return it to the nurse's office in the building your student attends.

You can download the form from our district website.

Health Services Consent

School of the Osage has a licensed school nurse in each building to provide basic school health services. The school health program is not to replace the care your child receives from their regular doctor or clinic. We recommend your child receive a regular check up each year. The school health services program provides:

Immunizations: I understand that the Missouri State Law requires students to be properly immunized. I understand that I must provide documentation of month, day, and year of each immunization before my child may attend school. Religious (Imm.P.11A) and Medical (Imm.P.12) exemptions are allowed. The appropriate exemption card must be on file. Unimmunized children are subject to exclusion from school when outbreaks of vaccine-preventable diseases occur.

Screenings Permissions: Based on the District’s assessment plan, I agree to have my student participate in the following screenings:

Vision*

Hearing*

Dental *

Emergency Statement: I hereby authorize the school to seek emergency medical help, including an ambulance, if I cannot be contacted. I authorize emergency personnel to carry out diagnostic and emergency care as deemed necessary. I understand that the school does not assume responsibility for payment of any medical services. I understand that basic first aid and emergency care will be provided as needed by health services staff and other school staff including but not limited to the use of EPIPEN, albuterol nebulizer solution, oxygen therapy and AED. *

Immunization record upload is only enabled for new students.

Please indicate if this student has permission to go on all local field trips during this school year. Local includes Osage Beach, Lake Ozark, Eldon and Camdenton areas. Notes explaining the trips will still be sent home with your students with details of the trips.

We need parent permission to use a student's photograph, voice, and/or name in various media projects.

Yes- OPT IN: I consent. For and in consideration of the opportunity and privilege of appearing in or participating in one or more video or audio recordings, sound tracks, films, photographs, or written articles, I hereby consent to the use and editing thereof and release the School of the Osage District and its employees and assignees from any and all claims resulting from such use and editing in District media, and use, sale, editing and release to the newspapers, radio and television stations, and use on the internet.

No- OPT OUT: I do not consent to non-School of the Osage use of my child's photograph, voice and/or name in various media projects.

Parent-Signed media Releases are NOT needed when:

• Photographing or videotaping anonymous students engaged in normal classroom/school activities
• Photographing, videotaping or interviewing students at events that are open to the public, such as music, theater or athletic events.

Parent-Signed Media Releases are ALWAYS needed when:

• Students are interviewed or will be identified by name in a photograph/news article
• An individual student(s) is the focus of the story
• Photographing, videotaping or interviewing students who are in special education classes/services or certain specialized programs (drug/alcohol, detention/work detail, etc.)
• You feel the photograph, videotape or interview may be used in a negative way

What to do when the media makes an unscheduled call:

• Principals are encouraged to talk with the media regarding routine events, activities or issues at their schools.
• School principals may deny the photographing, videotaping and interviewing of students and staff on school grounds if it would disrupt the educational process.
• If the reporter/photographer is behaving poorly, or is pursuing a story that makes you uncomfortable about cooperating with him/her, contact the Central Office, 573.365.4091

In the event of a serious accident or in regards to issue of crimes, child abuse, etc. contact the Central Office, 573.365.4091, so a procedure may be prepared to handle media inquiries.

Origin: DESE Student Core and FCC

Please choose which of the following best describes your Wi-Fi/Internet capabilities within your home.

My household has reliable high-speed internet access including data/streaming without caps or restrictions. My household has internet access but limits on data/streaming, including data caps or slow speeds. My household does not have reliable internet access. * School of the Osage is able to provide access to cellular data service (through the FCC) to families who have an unmet need with regards to connectivity. This means you do not have access to adequate high speed internet at your home or cannot afford adequate access to high speed internet at your home.

Please fill out the linked Google Form if you would like cellular data service activated on your student(s) ipad(s).

https://docs.google.com/forms/d/e/1FAIpQLScWFREaWBkvaI0eqXbXq3euzS6vUCY3f0mwugwY0bX30wygjg/viewform?scrlybrkr=c9dba576

A copy of each school's student handbook is available on the school website.

I, the student, agree to follow all policies, procedures, and rules.*

Please have your student initial here to indicate they read, understand and consent to the above information. *

Origin: High School Scope: 9th-12th

Will this student be driving a vehicle to school this year? Yes No

All vehicles a student may drive to school must be registered in the high school office. If the student trades cars during the school year, the student is responsible to register the new car.

The “hang tag” must be displayed at all times on the rear view mirror when the car is parked on school property.

Any student that is parked illegally may be towed at the owner’s expense. (Examples: Car is parked in a handicapped parking spot, no parking zone, fire lane or not in an assigned parking space.)

Make: * Model: * Color: * Year: * License Plate Number: * License plate field(s): Use CAPITAL LETTERS (No space or hyphen)

Example: CHS123

Board of Education policy JFG states that it is a privilege, not a right, to park on school grounds. The school retains the authority to conduct routine patrols of any vehicle parked on school grounds. The interior of a student's automobile on school premises may be searched if the school authority has a reasonable suspicion to believe that such a search will produce evidence that the student has violated or is violating either the law or district policy. Students are required to register their automobiles with the office and display the appropriate parking permit at all times. There are to be no student cars parked or driven in the designated faculty area. All vehicles parked on school lot will be subject to search by school and/or law enforcement officials. Students are to enter the school immediately after parking. Students may not leave the school grounds once they have arrived at school unless given permission by school staff. Student drivers will not be permitted to the student parking area and/or leave school grounds until dismissed by the bus duty supervisor. Students who cannot enter or leave the lot at a reasonable speed will lose their parking privilege. A ten dollar ($10) replacement fee will be required for lost or misplaced parking passes.

I agree to obey all driving and parking regulations and understand that my vehicle may be towed at my expense if I park in an illegal parking space. Please have your student initial here. This will be considered the student's electronic signature. *

Origin: Activities Office, MSHAA Scope: 7th Grade thru 12th Grade

Activities / Athletics Does this student intend to participate in any of the following activities this school year? * Baseball Basketball Cross Country Dance Football Golf Band Choir Scholar Bowl Cheer Soccer Softball Speech Debate Theater Tennis Track Volleyball Wrestling

The following questions are required by MSHSAA: Has the entire family had a complete change of residence? (By-law 238) (Everyone living in the household at the previous address moved to the new address)* Previous Home Address:* What was the date this student moved to the new address?* Name of previous school attended* Dates attended (ex. 9/1/11-5/30/12)* Student's gender identity:* Month and Year of student's last physical (ex. 01/2011):*

Has student been diagnosed with a medical or health condition since last PPE (physical)?* If yes, please describe:*

PARENT PERMISSION (Authorization for Treatment, Release of Medical Information, and Insurance Information) Informed Consent: By its nature, participation in interscholastic athletics includes risk of serious bodily injury and transmission of infectious disease such as HIV and Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning program, and inspect their own equipment daily. PARENTS, GUARDIANS, OR STUDENTS WHO MAY NOT WISH TO ACCEPT RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN MSHSAA- SPONSORED SPORT WITHOUT THE STUDENT’S AND PARENT’S/GUARDIAN/S SIGNATURE.

I understand that in the case of injury or illness requiring transportation to a health care facility, a reasonable attempt will be made to contact the parent or guardian in the case of the student-athlete being a minor, but that, if necessary, the student-athlete will be transported via ambulance to the nearest hospital.

We hereby give our consent for the above student to represent his/her school in interscholastic athletics. We also give our consent for him/her to accompany the team on trips and will not hold the school responsible in case of accident or injury whether it be en route to or from another school or during practice or an interscholastic contest; and we hereby agree to hold the school district of which this school is a part and the MSHSAA, their employees, agents, representatives, coaches, and volunteers harmless from any and all liability, actions, causes of action, debts, claims, or demands of every kind and nature whatsoever which may arise by or in connection with participation by my child/ward in any activities related to the interscholastic program of his/her school.

In the event of an emergency or when the Parent(s) or Guardian is unable to directly supervise health care services needed by the student for injuries or illnesses sustained at any athletic practice, conditioning exercise or contest, I also give my consent to the rendering of necessary health care services for the student by a qualified provider (QP) covering the athletic practice, conditioning exercise or contest, including an athletic trainer, physician, physician assistant, nurse practitioner or other medically-trained professional licensed by the State of Missouri (or the state in which the student injury or illness occurs) and who is acting in accordance with the scope of practice under their designated state license and any other requirement imposed by state law. In emergency situations, the QP may also be a certified paramedic or emergency medical technician for the purpose of providing emergency health care and transport. Health care services are defined as services including, but not limited to, evaluation, diagnosis, first aid, emergency care, stabilization, treatment and referral. I further authorize the QP who provides such health care services to disclose such information about the student’s injury or illness, diagnosis, care and treatment in the professional judgment of the QP to the student’s athletic director, coaches, school nurse and any classroom teacher required to provide academic accommodation to assure the student’s recovery and safe return to activity. If the Parent(s) or Guardian believes that the student is in need of further evaluation, treatment, rehabilitation or health care services for the injury or illness, the student may be treated by the physician or provider of his or her choice.

To enable the MSHSAA to determine whether the herein named student is eligible to participate in interscholastic athletics in the MSHSAA member school, I consent to the release of any and all portions of school record files to MSHSAA, beginning with seventh grade, of the herein named student, specifically including, without limiting the generality of the foregoing, birth and age records, name and residence address of parent(s) or guardian(s), residence address of the student, academic work completed, grades received, and attendance data.

We confirm that this application for the above student to represent his/her school in interscholastic athletics is made with the understanding that we have studied and understand the eligibility standards that our son/daughter must meet to represent his/her school and that he/she has not violated any of them. We also understand that if our son/daughter does not meet the citizenship standards set by the school or if he/she is ejected from an interscholastic contest because of an unsportsmanlike act, it could result in him/her not being allowed to participate in the next contest or suspension from the team either temporarily or permanently. I consent to the MSHSAA’s use of the herein named student’s name, likeness, and athletic-related information in reports of contests, promotional literature of the Association and other materials and releases related to interscholastic athletics.

We further state that we have completed that part of this certificate which requires us to list all previous injuries or additional conditions that are known to us which may affect this athlete's performance or treatment and we certify that it is correct and complete.

The MSHSAA By-Laws provide that a student shall not be permitted to practice or compete for a school until it has verification that he/she has basic health/accident insurance coverage, which includes athletics. Our son/daughter is covered by basic health/accident insurance for the current school year as indicated on the Health Services page of this online registration.

STUDENT AGREEMENT (Regarding Conditions for Participation) This application to represent my school in interscholastic athletics is entirely voluntary on my part and is made with the understanding that I have studied and understand the eligibility standards that I must meet to represent my school and that I have not violated any of them.

I have read, understand, and acknowledge receipt of the MSHSAA brochure entitled “How to Maintain and Protect Your High School Eligibility,” which contains a summary of the eligibility rules of the MSHSAA. (I understand that a copy of the MSHSAA Handbook is on file with the principal and athletic administrator and that I may review it in its entirety, if I so choose. All MSHSAA by-laws and regulations from the Handbook are also posted on the MSHSAA website at www.mshsaa.org).

I understand that a MSHSAA member school must adhere to all rules and regulations that pertain to school-sponsored, interscholastic athletics programs, and I acknowledge that local rules may be more stringent than MSHSAA rules.

I also understand that if I do not meet the citizenship standards set by the school or if I am ejected from an interscholastic contest because of an unsportsmanlike act, it could result in me not being allowed to participate in the next contest or suspension from the team either temporarily or permanently.

I understand that if I drop a class, take course work through Post -Secondary Enrollment Option, Credit Flexibility, or other educational options, this action could affect compliance with MSHSAA academic standards and my eligibility.

I understand that participation in interscholastic athletics is a privilege and not a right. As a student athlete, I understand and accept the following responsibilities:

• I will respect the rights and beliefs of others and will treat others with courtesy and consideration.

• I will be fully responsible for my own actions and the consequences of my actions.

• I will respect the property of others.

• I will respect and obey the rules of my school and laws of my community, state, and country.

• I will show respect to those who are responsible for enforcing the rules of my school and the laws of my community, state, and country.

I have completed and/or verified that part of this certificate which requires me to list all previous injuries or additional conditions that are known to me which may affect my performance in so representing my school, and I verify that it is correct and complete.

Concussion Materials I accept responsibility for reporting all injuries and illnesses to my school and medical staff (athletic trainer/team physician) including any signs and symptoms of a CONCUSSION. I have received and read the MSHSAA materials on Concussions, which includes information on the definition of a concussion, symptoms of a concussion, what to do if I have a concussion and how to prevent a concussion. I will inform my school and athletic trainer/team physician immediately if I experience any of these symptoms or if I witness a teammate with these symptoms.

PARENT/GUARDIAN AND STUDENT SIGNATURE

Initial here to indicate you have read, understand and consent to the above information and responsibilities.

Student Initial:* Parent/Guardian Initial:* Student and Parent/Guardian Initial Date (ex. 01/01/2011):

Is this student 18 years of age and not residing with the parent/guardian? Yes No

The student will need to pick up and sign a School of the Osage District Drug Testing Consent Form from the Athletic Director's office.

I have read and completely understand the district’s policy and procedures regarding the School of the Osage student drug testing program.*

I understand that students who wish to drop out of the drug testing pool must first have their parent/guardian come to the school and meet with the Activities Director and/or Principal. The student and parent/guardian must sign a release form stating they no longer wish to participate in the random drug testing pool. If the student is 18 years of age and does not reside with a parent/guardian the student’s signature is all that is required. Once a student enters the pool, he/she must remain in the pool for the remainder of that school year to be eligible to participate in co-curricular and/or extra-curricular activities as well as student parking privileges.*

I have received, read, understand and agree to abide by the School of the Osage drug testing policy and procedures. As a condition of my student's participation in activities at School of the Osage, I authorize the district to collect urine specimens from my student and authorize the district to have the specimens tested for illegal drugs, performance-enhancing drugs and alcohol. I also authorize the release of information concerning the results of such a test to School of the Osage.*

I understand this consent form is effective until the student withdraws from the drug testing program, transfers to another school district or graduates.*

Campus Tool: Student Information > General > Extended Learning

Campus Tool: Student Information > General > Transportation OLR

Survey, Analyzing, or Evaluating Students - Notice and Opportunity to Opt Out

(BOE Policy JDHA)

Purpose: School of the Osage has a survey plan for the purpose of elevating student voice and ensuring continuous improvement for the school district. Do you want your student to participate in the district level approved Survey Plan 2022-2023?

Yes - I want my student to participate in all surveys included in the School of the Osage District survey plan for the 2022-2023 school year.

No - I do not want my student to participate in all surveys included in the School of the Osage District survey plan for the 2022-2023 school year.*