Pyc Student Information Form - Columbus School For Girls
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3PYC Student Information Form
(Parent/Guardian signatures required annually)
Program for Young Children
56 S. Columbia Ave.
Columbus, Ohio 43209
Phone: 614.252.0781
Fax: 614.252.0571 Attn: Sam Affholter, Administrative Assistant
To be completed by the Student’s Parent/Guardian:
Student Name:__________________________________________ Form:__________ Date of Birth:_______________
EMERGENCY CONTACTS
We will always call you first. Parents cannot be listed as emergency contacts. List the name and contact information of at least two people
who can be reached in the event of an emergency or illness if you cannot be contacted. Any person listed should be able to assist in
contacting you. At least one person listed must be within one hour of the school, able to take responsibility for the child in case the
parent/guardian cannot be reached, and should be at least 18 years of age. If you would like to add additional contacts, please attach
and send them on an additional page.
Name:
Relationship to Child:
City & State:
Daytime Phone:
Cell Phone:
Name:
Relationship to Child:
City & State:
Daytime Phone:
Cell Phone:
MEDICAL CONTACTS
ALL information is required and must be complete. In the event reasonable attempts to contact me have been unsuccessful, I hereby
give my consent for (1) the administration of any treatment deemed necessary by the below-named doctors, or, in the event the designated
preferred practitioner is not available, by another licensed physician or dentist; and (2) transfer of my child to the closest hospital. This
authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring for such
surgery, are obtained prior to the performance of such surgery.
Physician Name:
Phone:
Address:
Dentist Name:
Phone:
Address:
Other Name/Specialization:
Phone:
Address:
ADMINISTRATION OF OVER-THE-COUNTER PRODUCTS
Please select which medications may be given to your daughter. 1) I understand that I am responsible for providing the over-the-counter
products selected below. Products are clearly labeled with child's name and provided in a clear, re-sealable plastic bag. 2) If specific
dosing instructions are provided on the label, my child falls within the stated guidelines. If my child does not fall within these guidelines,
a physician's signed authorization will be provided. 3) Dosage will be administered according to label guidelines. 4) Products will be kept
at school for the duration of time they are being administered.
Ibuprofen (provided by nurse)
Sunscreen
Antibacterial gel/lotion
Benadryl (provided by nurse)
Hand or body lotion
Anti-itch cream/gel
Other:__________________
Acetaminophen (provided by nurse)
Lipbalm
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