Preschool Authorizations – Saint Jude the Apostle Catholic Church

Preschool Emergency Information and Pick Up Authorization

This field is for validation purposes and should be left unchanged.

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 Authorization

In addition to us as parents, only the people listed below have permission to pick up my child(ren).

Name

First Last

Phone

Relationship

Name

First Last

Phone

Relationship

Name

First Last

Phone

Relationship

Number of children attending Preschool?(Required)

Please enter a number from 1 to 2.

Child #1

Child's Name(Required)

First Last

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

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

List medications and reason for taking(Required)

Name of Pediatrician

First Last

Phone of Pediatrician

Child #2

Child's Name(Required)

First Last

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

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

List medications and reason for taking(Required)

Name of Pediatrician

First Last

Phone of Pediatrician

Additional Information

Preferred Hospital

Have there been any major changes in the family during the past year? (A new home, death in the family, divorce, job change, etc.)

Signature