Open House Childcare

Family Information

Child's Name *

Name of Parent/Guardian Picking Up Student *

Parent/Guardian Picking Up Phone *

Medical Information

Does your child have any allergies? If yes, please describe in detail. *

Does your child have any medical conditions or concerns that the school needs to know about or that may impact their full participation in all school activities? If yes, please describe in detail. *

Permission and Release- Please enter your initials in the spaces below for each field with which you agree.

1. I hereby grant permission for my child to use all of the play equipment and participate in all activities of the school. *

2. I hereby grant permission for the Director or authorized school personnel to take any steps necessary to obtain emergency medical care for my child, if warranted. These steps may include but are not limited to attempting to contact a parent, guardian, the child's physician or any of the persons mentioned cannot be contacted, school personnel may do any or all of the following: call another physician, call an ambulance, have the child taken to an emergency hospital in the company of a staff member. In the case of emergency, a physician and/or emergency and medical professionals may examine my child and administer such emergency medical treatment as deemed necessary. Without such permission, the school assumes no responsibility for emergency medical attention. Any expense incurred while enlisting the help of a medical personnel as listed above with be borne by the child's family. *

Parent/Guardian 1 Signature *

Parent/Guardian 2 Signature