Noah’s Park Christian Preschool

1732 S. Main St.

225-6755

Emergency Information and Authorization

Child’s Name _______________________________  Birthdate ____________________

Mother’s Name _____________________________  Home Phone ________________

Home Address ___________________________________________________________

Business Name ___________________________________________________________

Business Address _________________________________________________________

Occupation _____________________________________________________________

Days and Hours of Employment ______________________ Phone ________________

Father’s Name ________________________________ Home Phone _______________

Home Address ___________________________________________________________

Business Name ___________________________________________________________

Business Address _________________________________________________________

Occupation _____________________________________________________________

Days and Hours of Employment _______________________Phone _______________

PERSONS TO CONTACT IF PARENTS ARE NOT AVAILABLE

1.  Name _________________________________________ Phone ________________

Address ________________________________________________________________

Relationship to Child _____________________________________________________

2.  Name _________________________________________Phone ________________

Address ________________________________________________________________

Relationship to Child _____________________________________________________

Any carpool arrangements? _______________________________________________

Names of persons, other than parents, to whom the child may be released: _______________________________________________________________________

Names of person to whom the child MAY NOT be released _______________________________________________________________________

Food Allergies or Restrictions ______________________________________________

Child’s Doctor _______________________________ Phone _____________________

Address ________________________________________________________________

Child’s Dentist _______________________________ Phone _____________________

Address ________________________________________________________________

AUTHORIZATION

I hereby give my permission to Noah’s Park Christian Preschool to call a doctor for medical or surgical care for my child or to have my child taken to a hospital by ambulance, should an emergency arise and it is deemed necessary by the school.  I understand that a conscientious effort will be made to locate me or my spouse before any action will be taken, but if it is not possible to locate us, this expense will be accepted by us.

I also give permission for my child to attend occasional walks and field trips away from the school site.  I understand notices will be sent home in advance of field trips (not walks).  I further understand that the children will be transported by staff members and/or parents and that each child will ride with a seat belt fastened.

I also grant permission for my child to participate in video and audio-tape recordings, pictures of classroom procedures, etc. for use in any media produced by or on behalf of Noah’s Park Christian Preschool of Aberdeen.

I understand that Noah’s Park Christian Preschool may provide classroom experience for student teachers and interns and agree that student teachers and interns may be a part of my child’s classroom environment.

Parent Signature ___________________________________Date _________________