Pyc Student Information Form - Columbus School For Girls Page 3
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3Student Name:
Form:
CHILD PICKUP POLICY AND PERMISSION TO TRANSPORT
My child will attend school:
Half-Day (pickup at 12:20pm)
Full-Day (pickup at 3:00pm)
At the conclusion of the school day my child will:
Be picked up from the PYC
Attend the PYC After Hours Program
Ride the bus (5/6 only)
The following individuals have my permission to pick up my child (you may add or change at any time)
1.
5.
2.
6.
3.
7.
4.
8.
PER OHIO DEPARTMENT OF EDUCATION GUIDELINES
1) I agree that the above-named student may take part in any school-sponsored field trips, events, or activities. I must give
advance written notice if I wish to restrict any of my daughter's activities at any time. I authorize Columbus School for Girls
to provide transportation related to the program and these field trips.
2) I agree to have my name and contact information included in the CSG Parent/Student Directory which is available to
parents whose children are enrolled at Columbus School for Girls.
By signing below, I acknowledge that all information I have provided is accurate to my knowledge and I agree to all
aforementioned procedures in this form. I have read and understand that any prescription medication my daughter requires
during school MUST be accompanied by the Request for Administration of Medication form completed by her Physician. If
my daughter has ASTHMA, SEVERE ALLERGIES, or REQUIRES EPINEPHRINE, I, along with her Physician, recognize
that we must complete the corresponding PYC Care Plan and submit them before the start of school. For any other medical
condition requiring special or emergency instructions, I have contacted the school nurse with a completed Child
Medical/Physical Care Plan form. This form, after being completed and signed by the parent/guardian, must be reviewed
for completeness and signed by the administrator/designee prior to the child entering school.
Year One
Date:
Parent/GuargianSignature:
Administrator Signature:
Date:
Year Two Parent/Guardian
Date of Review:
Administrator Initials:
Date of Review:
Initials:
Year Three Parent/Guardian
Date of Review:
Administrator Initials:
Date of Review:
Initials:
* The administrator shall have the parent/guardian review and initial the form when any changes/updates are made and at
least annually. The parent/guardian and the administrator or designee shall initial and date the form upon future
date reviews.
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