Preschool Authorization & Emergency Care Form

Student Last Name: *

Student First Name: *

Nickname:

Date of Birth: (MM/DD/YYYY) * +

Sex: *

Grade: *

School: *

School Year: *

Street Address: *

City: *

State: *

Zip Code: *

Email for official school communication: *

Name and grade of any siblings at the school: *

Student lives with: *

Mother/Guardian First & Last Name: *

Mother/Guardian Address (street, city, state, zip): *

Mother Cell Phone #: *

Mother Home Phone #: *

Mother Work Phone #: *

Father/Guardian First & Last Name: *

Father/Guardian Address (street, city, state, zip): *

Father Cell Phone #: *

Father Home Phone #: *

Father Work Phone #: *

Child's Physician: *

Physician Phone Number: *

Insurance Company: *

Policy #: *

Outstanding Medical History (eg. diabetes, heart disease, contact lenses, hearing aid, etc.): *

Allergies: *

Action to Take: *

Student's Medications: *

Date of Last Tetanus Shot: * +

Emergency Contact #1 First & Last Name: **Please do not put a parent as an emergency contact if they are listed as a parent above!** *

Relationship to Student: *

Emergency Contact #1 Street Address: *

City: *

State: *

Zip: *

Emergency Contact #1 Phone Number(s): *

Emergency Contact #2 First & Last Name: **Please do not put a parent as an emergency contact if they are listed as a parent above!** *

Relationship to Student: *

Emergency Contact #2 Street Address: *

City: *

State: *

Zip: *

Emergency Contact #2 Phone Number(s): *

Please list any individuals who ARE allowed to pick up your child from St. Ambrose Preschool. **Please include both parents (if applicable) and your emergency contacts!** *

Please list any individuals who are NOT allowed to pick your child up from school: *

Consent to Share Information: I grant permission for the following information to be made available to the St. Ambrose Preschool Community:
Child's Name and Parents' names
Address
Home Phone Number
Email Address

Consent to Share Information: *

Yes

Consent to Participate: I grant permission for my child to use all play equipment, walk around school grounds for planned activities and to participate in all activities held at the school.

Consent to Participate: *

Yes

Consent for Treatment: I give my permission for qualified school personnel to provide routine health care and first aid to my child as may be necessary during school and after school activities. I assume full responsibility for providing the school with all necessary over the counter or prescription medications as well as necessary medical treatment supplies and authorization.

Consent for Treatment: *

Yes

Consent to Share Information: The school nurse and/or health aide have my permission to share my child's confidential health information, on a need-to-know basis, with appropriate members of the educational staff, primary healthcare providers, and extended day, for the use in meeting the educaitonal and health needs of my student. This consent includes the sharing of personally identifiable health record information during immunization and communicable disease surveillance audits by the Virginia Department of Health and the Virginia Department of Social Services for licensed program compliance, if applicable.

Consent to Share Information: *

Yes

Notification Agreement: I agree to notify the school within 24 hours if my child or any member of their immediate household has developed a communicable disease. I agree to notify the school immediately if the disease is life threatening. I agree to pick up my sick or injered child in a timely manner when contacted. If I cannot be reached, the above emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment, when a physician deems necessary for the well-being of my child.

Notification agreement: *

Yes

I certify that the information provided in this document is true and accurate to the best of my knowledge.

Parent/Guardian Signature: *

clear

Parent Printed First & Last Name: *

Date * +

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