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- The maximum number of form submissions has been reached. This form is currently not available.
  
  Mother/Guardian First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother/Guardian Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Email (Mother) REQUIRED Please fill out this field. Please enter an email address.
  
  Cell Phone Number (Mother) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Work Phone Number (Mother) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Father/Guardian First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Father/Guardian Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Street Address (if different than above) Please enter valid data.
  
  City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
  
  Email (Father) REQUIRED Please fill out this field. Please enter an email address.
  
  Cell Phone Number (Father) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Work Phone Number (Father) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Emergency Contact First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number (Emergency Contact) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Authorized Pick Up Person First Name Please enter valid data.
  
  Authorized Pick Up Person Last Name Please enter valid data.
  
  Authorized Pick Up Person Phone Number Maximum 20 characters Please enter a phone number.
  
  # of Enrolled Children REQUIRED Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 7
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 8
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 9
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  Child 10
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field.
  
  Will your child be attending before or after care? REQUIRED Please fill out this field.
  
  My student will arrive by: REQUIRED Please fill out this field.
  
  Bus # Please enter valid data.
  
  Do you want your child to receive Potassium Iodide in case of a nuclear event? REQUIRED Please fill out this field.
  
  Does your child weigh over 150lbs (for Potassium dosage)? REQUIRED Please fill out this field.
  
  Pre-K thru 3rd Milk Lunch Milk - Chocolate Lunch Milk - White Snack Milk - Chocolate Snack Milk - White Not ordering milk
  
  4-8 Milk Form (Select One) Lunch Milk - Chocolate Lunch Milk - White Not ordering milk
  
  There is a $10 non-refundable registration fee for Extended Care per child(ren), which will be applied towards your September payment. Please submit form and payment in a sealed envelope marked “Extended Day Care”. Please refer to website for new aftercare prices.
  
  Pre-K Milk Fees
  All Pre K students are provided milk for both snack and lunch. Milk is served in 8 ounce cartons.
  K-3 Milk Fees
  Lunch Milk Only: White - $37.00 Chocolate - $42.55
  Snack Milk Only: White - $37.00 Chocolate - $42.55
  Lunch & Snack Milk: White - $74.00 Chocolate – $85.00
  White/Chocolate - $80
  4-8 Milk Fees
  Lunch Milk: White $37.00 Chocolate $42.55
  
  Submit
  
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- Dear SJS Parents,
  
  The Governor of Maryland and the St. Mary’s County Commissioners have made the decision to have Potassium Iodide (KI) made available to those residents of the designated Emergency Planning Zone (approximately 10-mile radius) of the Calvert Cliff’s Nuclear Power Plant. The preventative medication, Potassium Iodide (KI) has been acquired at St. John’s School. In the event of a nuclear emergency at the Calvert Cliff’s Nuclear Power Plant, evacuation of schools with in the Emergency Planning Zone (EPZ) will be the primary goal. Potassium Iodide has been made available to the schools in the EPZ which include: Green Holly Elementary School, Town Creek Elementary School, Hollywood Elementary School, St. John’s School and Esperanza Middle School.
  Potassium Iodide (KI) taken shortly prior to an exposure to radiation blocks the absorption of radioactive iodide by the thyroid gland. It does not provide protection against any other form of radiation. Radioactive iodide may cause cancer of the thyroid 15-20 years after exposure. This timeline makes protecting children of primary importance. The St. Mary’s County Health Officer, and/or myself, is authorized to order the issuance and subsequent consumption of KI.
  
  Please review the Potassium Iodide information at www.fda.gov/drugs/emergencypreparedness/bioterrorismaddrugpreparedness/ucm072265.htm.
  
  Selecting "Yes" to the question "Do you want your child to receive Potassium Iodide in case of a nuclear event?" on the submission form is your signature indicating that you have elected to authorize the administration of Potassium Iodide (KI) to your son/daughter if ordered by the St. Mary’s County Health Officer, and/or myself in case of a radioactive release from the Calvert Cliff’s Nuclear Power Plant.
  
  Individuals who are allergic to Iodide or shellfish should NOT take Potassium Iodide. This consent will remain in effect unless revoked by the parent or legal guardians. If you have any questions, please feel free to contact your health care provider, the school nurse via email at [email protected] , or the St. Mary’s County Health Department at 301-475-4316. The school must receive this form back for all registered students at St. John’s School on or before August 26, 2022.
  
  Yours In Christ,
  Susan McDonough
Other Parent Forms
- Medical Forms
- Other Forms
Medical Forms
- Allergy Action Plan
  
  Inhaler Authorization Form
  
  Medical Authorization Form
  
  Epipen Authorization Form
  
  Immunization Acknowledgement form (Grades K-8)
  
  Immunization Acknowledgement Form (Pre-K only)
Other Forms
- Volunteer Application
  
  Virtus Child Protection Instructions

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