Lakeside Weekday Education 2020-21 School Year Student Information Card

Lakeside Weekday Education 2020-21 School Year Student Information Card
Name*

Child’s first nameChild’s last name
Address*
City*
State*
Zip*
Home Phone number
Student’s birthdate*

MonthDayYear
Date
Mother’s name*
Mother’s cell*
Mother’s email*
example@example.com
Mother’s cell carrier*
Mother’s Work
Father’s work
Father’s Name
Father’s cell
Father’s email
example@example.com
Father’s cell carrier
In case of emergency and I cannot be reached
Phone number
Relation to the child
Lakeside Weekday Education 2020-21 School Year - Parent Release Form
I hereby authorize Lakeside Baptist Weekday Education staff to release my child to one of the persons listed below.
Mother
Father
Name of pick up person
Relation to child
Phone
Name of pick up person
Relation to child
Phone
Name of pick up person
Relation to child
Phone
Name of pick up person
Relation to child
Phone
Parent Signature*
Date*

MonthDayYear
Date
Parent Signature*

By signing I agree that the above information is true.

Lakeside Weekday Education 2020-21 School Year Allergy Form
Name of Child*
Date of Birth*

MonthDayYear
Date
(If checked this box, skip to the bottom, sign and date)

My child does not have any allergies that I presently know of.
Type of Allergy
Things to avoid
Symptoms of allergic reaction
Procedures to follow in case of reaction
1.
2.
3.
4.
5.
Parent Signature*
Date*

MonthDayYear
Date
Parent Signature*

By signing I agree that the above information is true.

Lakeside Weekday Education 2020-21 School Year Non-Prescription Medication Form
Child’s name*
Birthdate*

MonthDayYear
Date
I hereby give Lakeside Weekday Education staff permission to apply any of the following external preparations that are checked, in accordance with the directions for use on the

Please write in special instructions or write on the line if only a specific type (provided by the parent) is to be used.
Check items you give permission to be applied when needed

SunscreenBug sprayLotionNon-prescription ointments such as Desitin, Vaseline, etcAntibiotic ointmentTeething gelInsect sting wipe (in case of bee sting or ant bite)Hand sanitizer
Parent Signature*
Date*

MonthDayYear
Date
Parent Signature*

By signing I agree that the above information is true.

Lakeside Weekday Education 2020-21 School Year Medical Form
Child’s Name*
Date of birth*

MonthDayYear
Date
Emergency contact name
Emergency contact name

My child has physical or emotional problems which require special medication?
Phone
If yes, please give a brief explanation:
Communicable diseases your child has already had
List below any additional comments as to special problems of your child, e.g., throat/ear problems, Fevers, nervousness, temper tantrums, etc.
CONSENT FOR MEDICAL TREATMENT
- In the event that my child becomes ill or is injured while under school supervision, I approve the school authorities taking the following steps:
- Contact a parent or legal guardian of the student and follow his/her on instructions.
- In the event of an emergency when a parent or guardian cannot be reached immediately, the school authorities are hereby authorized to use their best judgement in contacting a properly licensed physician or in transporting my child to the nearest hospital for consultation and/or treatment. Such transporting is to be done by ambulance.
Parent Signature*
Date*

MonthDayYear
Date
By signing I agree that the above information is true.
Family Insurance Company
Telephone number
Address
Contract
Policy
If, in the opinion of a properly licensed and practicing physician, my child needs medical or surgical services which require my consent before being supplied, and I cannot be reached, I hereby authorize, appoint, and empower the director or her designated representative, to furnish on my behalf such written or oral authorization as may be so required.

Furthermore, I release the director or her designated representative, and the Lakeside Baptist Kindergarten and Mother’s Day Out from any liability which might arise as the result of medical service and treatment provided by any hospital or physician pursuant to such authorization, it being my desire that my child be furnished with such medical or surgical services as soon as possible after the need arises. I agree to be responsible for any cost of medical service or treatment of my child or children as the result of the above authorization and agree to indemnify and hold harmless the Lakeside Baptist Weekday Education, the director or representative, from any expenses incurred for said treatment or services.
Parent Signature*
Date*

MonthDayYear
Date
By signing I agree that the above information is true.

Lakeside Weekday Education 2020-21 School Year Personal Information Form
Child’s name*
I give my permission for parent’s name, child’s name, address, e-mail address, and phone number to be released for the purpose of: Birthday parties Room mother information Etc.I do not give my permission for any of the above personal information to be released.
Lakeside Weekday Education 2020-21 School Year Photo Release Form
With your permission, pictures of your child may be used in publications of Lakeside’s Weekday Education program and on our website. Names, nor any personal information will be used with a picture of your child.
I give my permission a picture of my child to be used in publications for the for Lakeside Weekday Education program or the Lakeside website. I understand that my child’s personal information will not be used with a picture.I do not give my permission for a picture of my child to be used in any publication or website, but I do give permission for a picture of my child to be sent through group e-mails or texts from my child’s teacher.I do not give my permission for a picture of my child to be used in any form.
Parent Signature*
Date*

MonthDayYear
Date
By signing I agree that the above information is true.

Lakeside Weekday Education 2020-21 School Year Activity and Check-in permissions
Child’s Name*
Below are permissions that DHR requires. We will have a “water day” at the end of the school year. We must have a “yes” in order for your child to participate. This is the only swimming/wading activity we will have during the year. If your child is in 3K or 4K, you need to circle “yes” for the first two items as well - sign and date so they can go on field trips.
I give permission for my child to participate in activities away from the facility

YesNo
Parent Signature/guardian*
Date*

MonthDayYear
Date
I give permission for my child to be transported by the facility.

YesNo
Parent Signature/guardian*
Date*

MonthDayYear
Date
I give permission for my child to participate in swimming/wading activities provided by the facility.

YesNo
Signature of parent/guardian*
Date*

MonthDayYear
Date
I give permission for my child to be checked in and checked out by Lakeside’s Director, Regina Houser, or Lakeside’s Assistant Director, Becky Jacks when my child comes through carpool or when I let them know that I forgot to check in or out.
Parent Signature*
Date*

MonthDayYear
Date
By signing I agree that the above information is true.
I understand that the Department of Human Resources does not inspect activities away from the childcare facility (home or center The childcare facility assumes full responsibility for such activities.
Parent Signature*
Date*

MonthDayYear
Date
By signing I agree that the above information is true.
I understand that my child’s school will take my child’s temperature at the beginning of each day and periodically throughout the day
Parent Signature*
Date*

MonthDayYear
Date
By signing I agree that the above information is true.

Lakeside Weekday Education 2020-21 School Year E-mail Authorization All communications from Lakeside to parents will be done through e-mail
Child’s name
Parents’ names
For financial statements

I am currently receiving e-mail for financial statements at the correct address/es, and no change needs to be made.
For Financial statements I would like to change/add the following e-mail address:
E-mail address
example@example.com
E-mail address
example@example.com
For parent memos

I am currently receiving e-mail for parent memos at the correct address/es, and no change needs to be made.
For parent memos, I would like to change/add the following e-mail addresses:
E-mail address for memos:
example@example.com
E-mail address for memos:
example@example.com
Parent Signature*
Date*

MonthDayYear
Date
By signing I agree that the above information is true.

Lakeside Weekday Education 2020-21 School Year Student Information Card

Lakeside Weekday Education 2020-21 School Year - Parent Release Form

Lakeside Weekday Education 2020-21 School Year Allergy Form

Lakeside Weekday Education 2020-21 School Year Non-Prescription Medication Form

Lakeside Weekday Education 2020-21 School Year Medical Form

CONSENT FOR MEDICAL TREATMENT

Lakeside Weekday Education 2020-21 School Year Personal Information Form

Lakeside Weekday Education 2020-21 School Year Photo Release Form