LIGHTHOUSE CHRISTIAN SCHOOL

Transcription

1 LIGHTHOUSE CHRISTIAN SCHOOL Application Process information Thank you for your interest in Lighthouse Christian School. The application process is as follows: STEP I: KINDERGARTEN: Please submit... Completed Application for Enrollment (one per family) Completed Educational Information Completed Parent Agreement Part 1 & 2 Completed Medical History and Consent forms (2 pages) Current immunization record on the required WA State CIS form with parent signature or WA State Certificate of Exemption form Completed Student Publication form Copy of state issued birth certificate Test fee in the amount of $45, per student ELEMENTARY (GRADES 1-5): Please submit... Completed Application for Enrollment (one per family) Completed Educational Information Completed Parent Agreement Part 1 & 2 Completed Medical History and Consent forms (2 pages) Current immunization record on the required WA State CIS form with parent signature or WA State Certificate of Exemption form Completed Student Publication form Copy of current and previous year s report cards Copy of most recent standardized test results Test fee in the amount of $45, per student MIDDLE SCHOOL (GRADES 6-8): Please submit... Completed Application for Enrollment (one per family) Completed Educational Information Completed Parent Agreement Part 1 & 2 Completed Medical History and Consent forms (2 pages) Current immunization record on the required WA State CIS form with parent signature or WA State Certificate of Exemption form Completed Student Publication form Completed Student Questionnaire Copy of current and previous year s report cards Copy of most recent standardized test results Test fee in the amount of $45, per student STEP II: After submitting the required Application forms and fees, parents will be contacted to set up an appointment for placement testing, for all grades. Additionally, incoming Middle School students will be tested for math placement. STEP III: After reviewing application information and testing results are completed, you will be contacted to schedule an interview with the Director of Education or the Elementary Principal. STEP IV: Upon acceptance, you will meet with the Admissions Office to complete enrollment paperwork and pay the registration fee(s). 1

2 APPLICATION FOR ENROLLMENT This application must be completed in its entirety and a $45.00 application fee (non-refundable) per child is due upon receipt. Students applying for kindergarten will need to enclose a copy of their birth certificate. All signatures are needed. Failure to do so will delay the enrollment process. Please list each student you are enrolling Student Name: Grade applying for: Age: Birth : / / Sex: M F Last First Middle Nickname (for school use) Month/Day/Year (please circle) Student Name: Grade applying for: Age: Birth : / / Sex: M F Last First Middle Nickname (for school use) Month/Day/Year (please circle) Student Name: Grade applying for: Age: Birth : / / Sex: M F Last First Middle Nickname (for school use) Month/Day/Year (please circle) Student Name: Grade applying for: Age: Birth : / / Sex: M F Last First Middle Nickname (for school use) Month/Day/Year (please circle) How did you hear about Lighthouse Christian School? Please list who referred you to Lighthouse Do you have family members associated (attending, alumni, etc.) with Lighthouse? Family Information (complete once per family) If parents are divorced or separated, who has legal custody of the child? Is either parent forbidden by court order from having equal access to the child or school records? Yes No Is there an active restraining order / parenting plan we should have on file? Yes No (It is the parent s responsibility to provide the school with a copy of any current restraining order, parenting plan or other court order regarding your child.) If the student does not live with their natural father and mother, student lives with: (please circle below) Natural mother only / Natural father only / Natural mother and stepfather / Natural father and stepmother / Guardian Name of Father / Stepfather / Guardian: (circle one) Address: Title Preferred First Name Last Name Home Phone: City & Zip: Cell or Pager: Employer: Occupation: Work Phone: Employer address_ Name of Mother / Stepmother / Guardian: (circle one) Address: Title Preferred First Name Last Name Home Phone: City & Zip: Cell or Pager: Employer: Occupation: Work Phone: Employer address TITLE FOR MAILING (circle): Mr./Mrs. Mr. Mrs. Miss Ms. Dr./Mrs. Othe r: _ 2

3 List other children in the home, their ages and where they attend school: Name of Grandparent(s): Address: First Name(s) Last Name Home Phone: City & Zip: Cell or Pager: TITLE FOR MAILING (circle): Mr./Mrs. Mr. Mrs. Miss Ms. Dr./Mrs. Othe r: _ Name of Grandparent(s): Address: First Name(s) Last Name Home Phone: City & Zip: Cell or Pager: TITLE FOR MAILING (circle): Mr./Mrs. Mr. Mrs. Miss Ms. Dr./Mrs. Othe r: _ Church Affiliation: Name of church attending Address _ City State Zip Pastor s Name Are you a member? Yes No Regularity of attendance 1x/week_ monthly holidays other Why would you like to enroll your child(ren) at Lighthouse Christian School. If you would like information about the LCS Tuition Grant program, please visit 3

4 Lighthouse Christian School Educational Information For admittance we require the name, address and phone number of your child s most recent school. We will be sending a recommendation form to your child s former teacher. FOR KINDERGARTEN ONLY: Is your child currently in preschool? Yes No School last attended School Phone Address City State Zip _ Most Recent/Former Teacher List any major areas of difficulty your child has had in school. _ Tested/qualified for: Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP) or other individualized learning plan? Yes No _ (Please include a copy of the most recent plan) Has your child ever been suspended or expelled from school? Yes No _ If yes, please explain: 4

5 Lighthouse Christian School Parent Agreement Part 1 MISSION STATEMENT, CORE VALUES AND STATEMENT OF FAITH OUR MISSION: Lighthouse Christian School exists to glorify God by providing quality, Christ-centered education that will nurture students to become spiritually minded, academically versed, socially balanced, and equipped to make a positive impact in their community to the glory of our Lord Jesus Christ. CORE VALUES: GOD Absolute dependence on God which supports a vibrant relationship with Jesus Christ through the Holy Spirit as evidenced by: Regard for the Bible as the inspired Word of God and the only inerrant authority for faith and practice Reliance on prayer Commitment to a lifelong study of the Bible in order to bring our lives into conformity to the image of Christ A Christian worldview life viewed through the filter of God s Word PEOPLE Individual worth and uniqueness of each student Modeling a Godly lifestyle Godly relationships with open communication Teachers who nurture, respect, and care for each student Partnering with committed and involved parents EDUCATION Pursuit of academic excellence Teaching for transformation toward spiritual maturity in Christ Integration of Christian worldview into all subject matter Passionate teachers who motivate and inspire students Well-rounded traditionally-based academic program STATEMENT OF FAITH We believe in the Bible alone as the inspired Word of God, the only unerring authority for our Christian faith and life (2 Timothy 3:15-17). We believe in one true God, our eternal creator, an infinitely perfect being, existing in three persons: Father, Son, and Holy Spirit (Isaiah 40:28; 44:6-8; Matthew 28:19). We believe in God the Father, the ruler of the universe and our heavenly Father (1 Timothy 1:2; 6:15, 16). We believe in Jesus Christ, the only begotten Son of God, true God and true man, our crucified and risen Savior and Lord; in His virgin birth; His sinless life; His miracles; His vicarious and atoning death through His shed blood; His literal, bodily resurrection; His ascension to the right hand of the Father; and His personal, bodily return in power and glory (John 1:1-18; Isaiah 7:14, 9:6; Matthew 1; 2 Corinthians 5:21; 1 Corinthians 15; Hebrews 1, 9, 10). We believe in the Holy Spirit, who made us God s children by the new birth when we trusted Jesus Christ, and who is at work in our hearts prompting obedience and love for God (Romans 5:5; 8:13-17). We believe that all people have sinned against our holy and righteous God, and are therefore worthy of God s judgment (Romans 3:23; 6:23). We believe in the good news, that Jesus Christ died, bearing the penalty for our sins and was buried, that He rose again to provide forgiveness and eternal life for all who, by the grace of God, trust in Him alone (1 Corinthians 15:1-4; Romans 10:9-10). We believe in the grace of God, who has saved us, not because of who we are or what we have done, but as a gift received by faith alone (Titus 3:5-7; Ephesians 2:8-9). We believe in the universal church, invisibly uniting all true believers in our Lord Jesus Christ as brothers and sisters (1 Corinthians 12:12-13). We believe in local churches, visible gatherings of believers, for worship, fellowship, instruction, and service for Christ (Acts 2:42-47). We believe in the resurrection of both the saved and the lost; they that are saved unto the resurrection of life, and they that are lost unto the resurrection of damnation (John 5:28-29; 1 Corinthians 15). 5

6 Lighthouse Christian School Parent Agreement Part 1 (cont.) MISSION STATEMENT, CORE VALUES AND STATEMENT OF FAITH PARENT AGREEMENT We believe that in order to preserve the function and integrity of Lighthouse Christian School as a local Body of Christ, and to provide a Biblical role model to the Lighthouse Christian School members and the community, it is imperative that: All persons employed by LCS in any capacity agree to this Mission Statement, Core Values, and Statement of Faith, and instruct their students in light of its tenants. All volunteers read the Mission Statement, Core Values, and Statement of Faith, and agree to adhere to it or defer to administration regarding any topic they may disagree with. For families that attend LCS, it is strongly encouraged that they read the Mission Statement, Core Values, and Statement of Faith, and agree to it. For the family that does not agree with the Mission Statement, Core Values, and Statement of Faith, they must agree to not be divisive about these issues within the school body. LCS encourages any family that does not wholeheartedly agree with the Mission Statement, Core Values, and Statement of Faith to consider if this school is a good fit for their family, as their children will be instructed in light of these tenants, which could prove contrary to what the student will be learning and witnessing in the home. I have read and understand the LCS Mission Statement, Core Values, and Statement of Faith. I agree to support the school s Mission Statement, Core Values, and Statement of Faith. Student Name: _ X _ Parent/Guardian Signature X _ Parent/Guardian Signature 6

7 Lighthouse Christian School Parent Agreement Part 2 SCHOOL OPERATIONS 1. Parental Involvement: We have the understanding that the goals of the school cannot be fulfilled without parental involvement. This involvement shall include, but not limited to: support of the policies and procedures outlined in the Parent/Student Handbook, participation in fundraising activities, attendance at school functions and parent meetings, support of the homework policy, reading information sent home from the school, and communication with our child s teacher(s). 2. Discipline and Conduct: The school shall have authority to discipline our child when necessary in accordance with applicable Washington State Laws and will require our child to comply with all school regulations and policies. We agree that we will cooperate and discipline our child in the home as needed. We understand that a child who persists in unacceptable conduct will not be permitted to remain in school. We further agree to require our child to show respect for those in authority over them in school including teachers, assistants, administrator, staff, and parent volunteers. 3. Damages: We will pay for damages caused by our child. 4. Liability: We release Lighthouse Christian School from all liability, except negligence, while our child is under school care and responsibility. 5. Placement: We understand that the school has full discretion in the class placement of our child. 6. Grievances: We understand that conflicts may arise that adversely affect the operation of Lighthouse Christian School arising between and/or within the Board of Directors, the Administration, the staff, the volunteers, and the parent body. We shall first attempt to resolve conflicts internally through appropriate channels following the model of Matthew 18. If the conflict continues, we agree to seek the assistance of a Christian mediator. 7. Financial Agreement: We agree to fulfill all financial obligations promptly through FACTS. We understand that a late charge of $25.00 will be added to our FACTS account if our payment is more than 5 days late. We understand that if the account is delinquent 2 months, our account may be sent to a collection agency and our student may be dis-enrolled. We understand that to re-enroll our child(ren), our account must be brought up to date. We also agree that registration fees and curriculum fees are nonrefundable. NSF checks will result in a $30.00 charge to our FACTS account. Tuition payment options are available as follows: 1. One annual payment due on or before September 15th monthly payments (August May) through FACTS a. Automatic draft withdrawal recurring on the 5th of each month, or b. Automatic draft withdrawal recurring on the 20th of each month. 8. Early Withdrawals: For all early withdrawals, advanced written notice must be received by the principal 30 days prior to the anticipated last date of attendance. If written notice is received, as stated above, tuition obligation shall be only to the end of the last month of attendance. If a student is withdrawn without a 30 day advance written notice, the parent/guardian shall be responsible for payment of tuition for the last month of attendance plus the following month. All school property must be returned and all current tuition and fees paid before the school will authorize withdrawal and release grades and transcripts. I acknowledge that I have read this agreement carefully and hereby agree to its terms. I understand my financial obligations as stated above. Two signatures are required if student resides with both parents. Student Name: _ X Parent/Guardian Signature X Parent/Guardian Signature 7

8 Lighthouse Christian School MEDICAL HISTORY Page 1 Student Name: 2019/20 Grade: _ :_ Does your child currently have or has your child previously had any of the following? If YES, explain briefly. Please answer all questions by circling Y=Yes N=No Allergies to medication Y / N List: Other Allergies (Food, etc) Y / N List: Epipen? Frequent Headaches Convulsions/Seizures Hearing Impairment Y / N Y / N Y / N Visual Impairment Y / N Glasses needed? Asthma Y / N Inhaler needed at school? Hay Fever Y / N Seasonal? Heart Abnormality Y / N If so, are there limitations? Kidney Disease Y / N _ Blood Disease Y / N Frequent Nosebleeds Y / N Diabetes Y / N On Insulin? Hypoglycemia Skin problems/rashes Y / N Y / N Diagnosed-ADD/ADHD Y / N Medication? Emotional Concerns Y / N Life Threatening Condition Y / N _ Please List any Medications being taken: _ Please List any Medications to be taken at school: of Last Physical Exam:

9 Lighthouse Christian School MEDICAL HISTORY Page 2 Student Name Birth _/_/_ Male Female Last First Middle Month Day Year Grade Entering Please give the names and contact information of parents/stepparents/guardians with whom the student lives. Name: Relation to student: Last First Middle Address: City: Zip: _ Home #: Cell #: Work #: _ Name: Relation to student: Last First Middle Address: City: Zip: _ Home #: Cell #: Work #: _ Emergency Contacts: In case of emergency or injury, if parents cannot be reached, notify (please prioritize) Name Relationship to Student Phone (home/cell/work) Medical Insurance: All students attending LCS are required to have medical insurance coverage. LCS does not assume responsibility for such coverage. Insurance Company: ID # Group # Doctor s Name: Phone # Preferred Hospital: Phone # _ Consent for Hospital Admission and/or Physician s Care We agree that in the event our child becomes ill or sustains an injury while in the care of LCS, and LCS believes the illness or injury is of an urgent nature, 911 may be called and/or our child may be transported to the nearest hospital/medical facility for care. We hereby consent to all medical and surgical treatment by the attending physician and to the administration and performance of all examinations, administering of medicine, treatments, anesthetics, operations, x-rays, blood tests, transfusions, or other procedures which may be deemed necessary for my child during the stay at a hospital. If an illness or injury to our child is believed to be of a less serious nature, LCS personnel will evaluate and attempt to contact the parent for further instructions. We hereby agree to accept responsibility for any costs or charges that result from, are incurred by, or arise in connection with the care or hospitalization of our child. We furthermore agree to indemnity and hold harmless LCS for all such costs or charges. I have read the above consent form and understand and agree to its content. (Both signatures are required) Signature of parent/legal guardian: : _ Signature of parent/legal guardian: : _

10 Certificate of Immunization Status (CIS) For Kindergarten-12 th Grade / Child Care Entry Office Use Only: Reviewed by: : Signed Cert. of Exemption on file? Yes No Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System. Child s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YY): Sex: I give permission to my child s school to share immunization information with the Immunization Information System to help the school maintain my child s school record. Parent/Guardian Signature Required I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Required for School and Child Care/Preschool Required Only for Child Care/Preschool DTaP / DT (Diphtheria, Tetanus, Pertussis) Tdap (Tetanus, Diphtheria, Pertussis) MM/DD/YY MM/DD/YY MM/DD/YY Required Vaccines for School or Child Care Entry MM/DD/YY MM/DD/YY MM/DD/YY Documentation of Disease Immunity Healthcare provider use only If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider Td (Tetanus, Diphtheria) I certify that the child named on this CIS has: Hepatitis B 2-dose schedule used between ages a verified history of Varicella (Chickenpox). Hib (Haemophilus influenzae type b) IPV / OPV (Polio) laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. MMR (Measles, Mumps, Rubella) PCV / PPSV (Pneumococcal) Varicella (Chickenpox) History of disease verified by IIS Recommended Vaccines (Not Required for School or Child Care Entry) Diphtheria Mumps Other: Hepatitis A Polio Hepatitis B Rubella Hib Measles Tetanus Varicella Flu (Influenza) Hepatitis A HPV (Human Papillomavirus) MCV / MPSV (Meningococcal) MenB (Meningococcal) Rotavirus Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed Name

11 Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand. To print with immunization information filled in: Ask if your healthcare provider s office enters immunizations into the WA Immunization Information System (Washington s statewide database). If they do, ask them to print the CIS from the IIS and your child s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at If your provider doesn t use the IIS, or call the Department of Health to get a copy of your child s CIS: waiisrecords@doh.wa.gov or To fill out the form by hand: #1 Print your child s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. #4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS. Reference guide for vaccine abbreviations in alphabetical order Full Vaccine Full Vaccine Abbreviations Abbreviations Name Name DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 DTaP DTP Flu (IIV) HBIG Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, Pertussis Influenza Hepatitis B Immune Globulin Reference guide for vaccine trade names in alphabetical order For updated list, visit Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1) Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix For updated list, visit Full Vaccine Full Vaccine Abbreviations Abbreviations Abbreviations Full Vaccine Name Name Name Meningococcal Conjugate Vaccine Hep B Hepatitis B MenB Meningococcal B Hib HPV (2vHPV / 4vHPV / 9vHPV) IPV Haemophilus influenzae type b Human Papillomavirus Inactivated Poliovirus Vaccine MPSV / MPSV4 DTaP + Hep B + IPV RotaTeq Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib + IPV Trumenba MenB Rotavirus (RV5) Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B MMR MMRV Meningococcal Polysaccharide Vaccine Measles, Mumps, Rubella Measles, Mumps, Rubella with Varicella If you have a disability and need this document in another format, please call (TDD/TTY call 711). DOH December 2016 OPV PCV / PCV7 / PCV13 PPSV / PPV23 Oral Poliovirus Vaccine Pneumococcal Conjugate Vaccine Pneumococcal Polysaccharide Vaccine Rota (RV1 / RV5) Rotavirus Td Tetanus, Diphtheria Tdap VAR / VZV Tetanus, Diphtheria, acellular Pertussis Varicella

12 Certificate of Exemption - Personal/Religious From School, Childcare, and Preschool Immunization Requirements Complete the box for the desired exemption type Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Gender: NOTICE: A parent or guardian may exempt their child from some or all vaccinations listed below by submitting this completed form to the child s school and/or child care. A person who has been exempted from a vaccination is considered at risk for the disease or diseases for which the vaccination offers protection. Exempted children/students may be excluded from school or child care settings and activities during an outbreak of the disease that they have not been fully vaccinated against. The diseases vaccines can protect against still exist, and can spread quickly in school and child care settings. Immunizations are one of the best ways to protect people from getting and spreading diseases that may result in serious illness, disability, or death. Personal/Philosophical or Religious Exemption Exemption Type: Personal/Philosophical Religious I am exempting my child from the requirement that my child be vaccinated against the following diseases to attend school or child care: Diphtheria Hepatitis B Hib Measles Mumps Pertussis (whooping cough) Pneumococcal Polio Rubella Tetanus Varicella (chickenpox) Parent/Guardian Declaration One or more of the required vaccines are in conflict with my personal, philosophical or religious beliefs. I have discussed the benefits and risks of immunizations with the health care practitioner below. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct. Parent/Guardian Name (print) Parent/Guardian Signature Health Care Practitioner Declaration I have discussed the benefits and risks of immunizations with the parent/legal guardian as a condition for exempting their child. I am a qualified MD, ND, DO, ARNP or PA licensed under Title 18 RCW, and the information provided on this form is complete and correct. Licensed Health Care Practitioner Name (print) MD ND DO ARNP PA Licensed Health Care Practitioner Signature Religious Membership Exemption Complete this section ONLY if you belong to a church or religion that objects to the use of medical treatment. Use the section above if you have a religious objection to vaccinations but the beliefs or teachings of your church or religion allow for your child to be treated by medical professionals such as doctors and nurses. Parent/Guardian Declaration I am the parent or legal guardian of the above named child. I affirm that I am a member of a church or religion whose teaching preclude health care practitioners from providing medical treatment to my child. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct. Parent/Guardian Name (print) Parent/Guardian Signature Name of Church or Religion of which you are a member: If you have a disability and need this form in a different format please call (TDD/TTY Call 711) DOH January 2018

13 Certificate of Exemption - Medical From School, Childcare, and Preschool Immunization Requirements Complete the box for the desired exemption type Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Gender: NOTICE: A parent or guardian may exempt their child from some or all vaccinations listed below by submitting this completed form to the child s school and/or child care. A person who has been exempted from a vaccination is considered at risk for the disease or diseases for which the vaccination offers protection. Exempted children/students may be excluded from school or child care settings and activities during an outbreak of the disease that they have not been fully vaccinated against. The diseases that vaccines can protect against still exist, and can spread quickly in school and child care settings. Immunizations are one of the best ways to protect people from getting and spreading diseases that may result in serious illness, disability, or death. Medical Exemption Licensed Health Care Practitioner (MD, ND, DO, ARNP, PA) completes this section. A health care practitioner may grant a medical exemption to a vaccine antigen required by rule of the state board of health only if in his or her medical judgment, the vaccine antigen is not advisable for the child. When it is determined that this particular vaccine antigen is no longer contraindicated, the child will be required to have the vaccine (RCW 28A ). Guidance for medical exemptions for vaccination can be obtained from the contraindications, indications, and precautions described in the vaccine manufacturer s package insert and by the most recent recommendations of the Advisory Committee on Immunization Practices (ACIP) available in the Centers for Disease Control and Prevention publication, Guide to Vaccine Contraindications and Precautions. This guide can be found at the following website: Please indicate which vaccine antigen(s) the medical exemption is referring to: Disease Permanent Temporary Expiration for Temporary Medical Diphtheria Hepatitis B Hib Measles Mumps Pertussis Pneumococcal Polio Rubella Tetanus Varicella I declare that vaccination for the disease/s checked above is not advisable for this child. I have discussed the benefits and risks of immunizations with the parent/legal guardian as a condition for exempting their child. I am a qualified MD, ND, DO, ARNP or PA licensed under Title 18 RCW, and the information provided on this form is complete and correct. Licensed Health Care Practitioner Name (print) MD ND DO ARNP PA Licensed Health Care Practitioner Signature Parent/Guardian Declaration I have discussed the benefits and risks of immunizations with the health care practitioner granting this medical exemption. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct. Parent/Guardian Name (print) Parent/Guardian Signature If you have a disability and need this form in a different format please call (TDD/TTY Call 711) DOH January 2018

14 LIGHTHOUSE CHRISTIAN SCHOOL School Year Student Publication Policy / Permission Dear Parent/Guardian: Throughout the school year, photo opportunities/multi-media opportunities exist both in the classroom and during special events. These opportunities may include, but are not limited to marketing materials (banner, brochures, flyers, ads, etc), theater productions, activities covered by media, award assemblies, and pictures posted on the school website and FaceBook. SCHOOL PUBLICATION/MEDIA PERMISSION FORM: I give permission for my child to be photographed and published, without their name, including the school website. Yes _ No Student Name: _ Grade for School Year: _ Parent Signature: _ : _ Parent Signature: _ : _