Student Information Form Page 2
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1
2Are there any custody issues:
Choose One
Explain:
Persons authorized to pick up the student & emergency contacts:
Name: _____________________________ Relationship: _________________ Phone: _________________
Name: _____________________________ Relationship: _________________ Phone: _________________
Name: _____________________________ Relationship: _________________ Phone: _________________
Medical Information:
(in the space below please list any pertinent medical history/concerns in eluding medications)
I grant permission for Kaleidoscope School of Discovery to administer prescribed and over the counter
medications for headaches, stomachaches, etc. as requested by the parent or student.
In case of illness, accident or injury to your child while attending Kaleidoscope School of Discovery or
participating in a achoo-related activity, I hereby give the staff of the school and volunteers permission to
administer first aid and to authorize emergency medical treatment if deemed necessary. I understand that I will
be financially responsible for any such treatment if needed.
Parent Printed Name: ____________________________________
Parent Signature: _______________________________________
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