Emergency Information / Authorization

Student Information

Student's Last Name*

Student's First Name*

Home Address*

Allergies or Medical Needs*

Yes

No

Please Explain*

Parent/Guardian Information

Parent/Guardian #1 Name*

Cell Phone*

Address (If different from above)

Place of Employment*

Employers Address*

Work Phone*

Days Worked*

Monday

Tuesday

Wednesday

Thursday

Friday

Hours*

Parent/Guardian #2 Name

Cell Phone

Address (If different from above)

Place of Employment

Employers Address

Work Phone

Days Worked

Monday

Tuesday

Wednesday

Thursday

Friday

Hours

If my child needs to leave school because of a minor illness and I/We cannot be reached, please call

Friend/Relative #1 Name*

Friend/Relative #1 Address*

Friend/Relative #1 Cell Phone*

Friend/Relative #2 Name*

Friend/Relative #2 Address*

Friend/Relative #2 Cell Phone*

In an EMERGENCY, I/We authorize the school to call our Pediatrician and if necessary 911

Physician Name

Physician Address

Physician Phone

Preferred Hospital

Persons Authorized to Transport Your Child

The following are authorized to pick up my child at any time

A written note is required when someone other than a parent/guardian or those above is picking up your child. All authorized persons may need to provide the teacher with proper identification.

Parent/Guardian Signature*

Reset

Date*

Field Trips

I give permission for my child to go on walking trips with Penfield Village Nursery School & Kindergarten.

Parent/Guardian Signature

Reset

Date