Rutgers Preparatory School Student Day Visit Form

Required

Student Namerequired

First Name

Last Name

Parent Email Addressrequired

Date of Birthrequired

Must contain a date in MM/DD/YYYY format

Date of Visit to RPSrequired

Must contain a date in MM/DD/YYYY format

Gender

Male

Female

Current Schoolrequired

Please list emergency contact numbers (available on the visitation day)

Emergency Contact 1required

First Name

Last Name

Home Phonerequired

Work Phonerequired

Mobile Phonerequired

Emergency Contact 2

First Name

Last Name

Home Phone

Work Phone

Mobile Phone

If your child has allergies/medical conditions/limitations, please state below.

If your child's medication needs to be available while he/she is visiting Rutgers Preparatory School, please bring the medication in the original labeled container and an Emergency Action Plan. Information will be shared with others.

Check all that apply

Asthma-requiring a rescue inhaler

Food or other allergy requiring epinephrine auto injector - please list allergies below

Diabetes - medications to be provided

Seizure disorder - medications to be provided

Any other medical conditions that require daily treatment

If you checked yes to any of the medical conditions above, please describe:

I hereby assume all risks to me and/or my child for personal injury and property damage or loss related to Student Day activities. I agree to indemnify and hold harmless Rutgers Prep, its trustees, officers, nurses, agents and employees (“Releasees”) from and against any and all claims or causes of action of any kind or nature whatsoever, and expenses, including attorneys’ fees, arising or claimed to have arisen out of any injuries or damages sustained by my child and/or me, unless such conduct is the result of the willful misconduct or gross negligence of the Releasees. I further agree to hold harmless and indemnify Rutgers Prep for any injuries or damages sustained by Rutgers Prep, the Releasees, or any other person or persons, as a result of intentional or negligent acts or omissions of me or my child. I understand that my child must abide by all Rutgers Prep rules and regulations, including its Code of Conduct.

In case of emergency, I authorize Rutgers Preparatory School to proceed with medical treatment.

Please sign your digital signature: (The electronic signature below is treated by Rutgers Preparatory School like a physical hand written signature on a paper form) *

Signaturerequired

First Name

Last Name

Daterequired

Must contain a date in MM/DD/YYYY format