Please download, sign and upload the Authorization to Give Medication form.
Please download, complete, sign and upload the Allergy Emergency Care Plan form.
Please download, complete sign and upload the Individual Health Care Plan form
Please download, complete, sign and upload the Asthma Action Card form
Please download, complete and upload the Diabetes Medical Management Plan
Please download, complete, sign and upload the Seizure Action Plan form
Special Power of Attorney: Consent to Authorize Medical Treatment for Minor Child
If in the event of an emergency, Heartwood ALC is unable to contact the above listed legal guardians, I hereby authorize an adult(s) from Heartwood ALC, in whose care said minor child has temporarily been placed, to authorize and consent to any medical treatment, procedure, or provision of medication of any kind for said minor child, solely in discretion and judgment of such above named adults, and to stand in my place in all respects concerning the care and provision of medical treatment to the minor child.
I hereby authorize any provider of medical services to rely on this consent form. I waive any claim against such provider with respect to any provision of medical treatment, including provision of medication, to such minor child, as instructed by the name adults to whom this power is granted, which claim would be based on an absence of parental consent for provision of medical treatment of minor child.
Internal Use*I give permission for my child to be included in any image recording connected with the school’s program which is purely intended for internal purposes. This might include posting to the internal-facing facebook account, internal-facing instagram account or ALC blogs that are intended to be shared with those inside the Heartwood ALC community. Please be aware it is possible that these forms of media may also be posted on the Internet at-large without the permission of Heartwood ALC.
External Use*I give permission for my child to be included in any image recording connected with the school’s program, specifically external-facing media. This might include postings to the external-facing facebook account, external-facing instagram account or ALC blogs that are intended to be shared with the ALC community worldwide. I understand that those images may be used as documentation on the school’s website, newsletter or marketing materials.
Field Trip Permission
I give permission for my child to participate in field trips that will require leaving the school grounds during and/or after school hours.
I understand that under present Georgia law, if my child is riding in a private passenger automobile which is involved in an accident, he/she may be primarily covered for bodily injury under my family automobile policy, and I agree to submit any medical bills incurred to my insurance company for payment and release Heartwood Agile Learning Center, including its agents and employees, from liability.
If my child is being transported by commercial carrier or other leased or rented vehicles and an injury occurs, I understand that I shall look to the commercial carrier or owner of the other leased or rented vehicle to pay any medical bills incurred as a result of such injury and shall release Heartwood Agile Learning Center, including its agents and employees, from liability.
If my child is injured while participating in the field trip, I agree and understand that liability arising out of said field trip is assumed hereby and shall be at the sole and exclusive risk of the undersigned.
Bright From the Start Exemption
I have been advised and understand that Heartwood Agile Learning Center is exempt from licensing through Georgia Department of Early Care and Learning’s Bright From the Start program. In addition I have been notified that Heartwood Agile Learning Center carries liability insurance.
This form will take you out of the current window to add your signature. Once you add your signature, you will need to COME BACK to this window and press "Submit" to complete the form. If you do not press "Submit" the form will not be accepted.