Directory And Release Information

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Directory and Release Information
Good Shepherd Lutheran Preschool
Phone: 301-963-1955
Accredited by the Maryland State Department of Education
Fax: 301-869-8126
16420 S. Westland Dr.
Email:
Gaithersburg, Maryland 20877
Website:
Directory Information
Child’s Name: ___________________________________________________________
Birthdate: ___________________
Street Address: ___________________________________________________________
Gender: ☐ Female ☐ Male
City/State/Zip: ___________________________________________________________
Phone: ______________________
Preferred Email Address: ______________________________________________________________________________________
May the information above, along with the parent/guardian names listed below, be published in the
☐ Yes ☐ No
GSLP Student Directory, distributed only to Preschool families?
Parent/Guardian Information
Adult 1
☐ Parent ☐ Guardian Gender: ☐ Female ☐ Male
Adult 2
☐ Parent ☐ Guardian Gender: ☐ Female ☐ Male
Full Name:
____________________________________
Full Name:
____________________________________
Occupation:
____________________________________
Occupation:
____________________________________
Mobile Phone:
____________________________________
Mobile Phone:
____________________________________
Work Phone:
____________________________________
Work Phone:
____________________________________
Email Address: ____________________________________
Email Address: ____________________________________
Is there a custody arrangement? ☐ Yes ☐ No
If yes, please provide a copy. Parents/guardians listed above are assumed
to have pick-up authorization unless a custody arrangement is provided.
Emergency Contact Information
GSLP must have two phone numbers for emergency contacts who can be given the details of any emergency situation and who
can make decisions concerning the child should GSLP be unable to reach the child’s parents/guardians. One phone number
must be an out-of-area number (i.e., a phone number that does not have a 202, 301, or 240 area code).
Local Contact Name: ______________________________________________________
Phone: ______________________
Out-of-Area Contact Name: _________________________________________________
Phone: ______________________
Child Release Authorization
The following persons (must be over age 16) have permission to pick up the above-named child from GSLP. You must list at
least two people. Parents listed above are assumed to have pick-up authorization unless a custody arrangement is provided.
Name: __________________________________________________________________
Phone: ______________________
Name: __________________________________________________________________
Phone: ______________________
Name: __________________________________________________________________
Phone: ______________________
Name: __________________________________________________________________
Phone: ______________________
Name: __________________________________________________________________
Phone: ______________________
Name: __________________________________________________________________
Phone: ______________________
In emergencies requiring immediate medical attention, 9-1-1 help will be summoned and your child will be taken to the nearest hospital
emergency room. You will be contacted as soon as possible. If permitted, a staff member will stay with your child until you arrive. Your signature
below authorizes the Good Shepherd Lutheran Preschool staff to have your child transported and treated by medical personnel.
_______________________________________________________________________
___________________________
Parent/Guardian Signature
Date
2016-2017
GSLP 2/11/16

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