Parental Consent Form - Preschool At Annunciation Greek Orthodox Church (Page 3 of 4) in pdf

Parental Consent Form - Preschool At Annunciation Greek Orthodox Church Page 3

Parental Consent Form

PAGE 3

Special Consent

Signature required beside each approved line.

__________________________ Administration of Minor First Aid Required For Admittance

__________________________ Emergency Medical Treatment Required For Admittance

__________________________ Emergency Medical Transportation Required For Admittance

__________________________ Administration of Non-Prescription Medication and Care Items

Dosage and use as per manufacturer instructions.

Acetaminophen

Rash Ointment

Sunscreen

Hand Sanitizer

Bandages

Antibiotic Ointment

Other: ___________________

__________________________ Walking Excursions Off Premises

__________________________ Field Trips

__________________________ Field Trip Transportation by Facility

If child is transported by facility, are there any special instructions for care?

(examples: Motion Sickness, Seizures) Yes _______ No _______

If yes, Explain: _________________________________________

Individuals Permitted to Pick Up Child

To ensure the safety of our children we must have on file a list of all individuals permitted to pick up your child

other than you or your spouse. WE WILL NOT RELEASE YOUR CHILD TO ANYONE WHO IS NOT LISTED

ON THIS FORM.

My child, _____________________________________ may be picked up from school by the following adults:

1. Name: ___________________________________________ Relation to Child: _________________

2. Name: ___________________________________________ Relation to Child: _________________

3. Name: ___________________________________________ Relation to Child: _________________

4. Name: ___________________________________________ Relation to Child: _________________

I understand that my child will not be released to any person other than myself, my spouse or the individuals

on this list unless I have provided a separate note to the teacher or preschool director giving my permission.

_____________________________________________________

_______________________

Parent/Guardian Signature

Date

Parental Consent Form - Preschool At Annunciation Greek Orthodox Church Page 3