Preschool Authorizations Preschool Emergency Information and Pick Up Authorization Mother's Name(Required) First Last Mother's Phone(Required)Mother's Email(Required) Father's Name(Required) First Last Father's Phone(Required)Father's Email(Required) Emergency Contact Name(Required) First Last Emergency Contact Phone(Required)Relationship(Required) Pick Up AuthorizationIn addition to us as parents, only the people listed below have permission to pick up my child(ren).Name First Last PhoneRelationship Name First Last PhoneRelationship Name First Last PhoneRelationship Number of children attending Preschool?(Required)Please enter a number from 1 to 2.Child #1Child's Name(Required) First Last Nickname Nickname Does this child have allergies or other medical conditions (e.g. diabetic, asthmatic, Mongolian spots/birthmarks, etc.)(Required)We require a doctor’s note for all food allergies, life-threatening and non life-threatening. Yes No Please list allergies and medical conditions here(Required)Does this child take any medications regularly?(Required)We ask that medications be administered at home. Yes No List medications and reason for taking(Required)Name of Pediatrician First Last Phone of PediatricianChild #2Child's Name(Required) First Last Nickname Nickname Does this child have allergies or other medical conditions (e.g. diabetic, asthmatic, Mongolian spots/birthmarks, etc.)(Required)We require a doctor’s note for all food allergies, life-threatening and non life-threatening. Yes No Please list allergies and medical conditions here(Required)Does this child take any medications regularly?(Required)We ask that medications be administered at home. Yes No List medications and reason for taking(Required)Name of Pediatrician First Last Phone of PediatricianAdditional InformationPreferred Hospital Medical Consent(Required)Should my child suffer any injury or illness while in the care of Saint Jude the Apostle Preschool and the preschool is unable to contact me immediately, the preschool shall be authorized to secure medical attention and care for my child as may be necessary. I agree to keep the preschool informed of changes in telephone and cell numbers where I can be reached. The preschool agrees to keep me informed of any incidents requiring professional medical attention involving my child. I agree to the medical policyHave there been any major changes in the family during the past year? (A new home, death in the family, divorce, job change, etc.)Signature Δ
