Back to School Form 2024-2025

Back to School Form

2024-2025
Name of Person Submitting Form:*

First NameLast Name
E-mail*

Confirmation Email
Family Name:*
Child's Name:*

First NameLast Name
Child's Class:*
Emergency Authorization and Information
Child's Birthday*

MonthDayYear
Date
Child's Age*
Child's Gender*
Child's Allergies*
Child's Medications*
Child's Medical Conditions*
Mom/Guardian Name*

First NameLast Name
Mom/Guardian Cell Phone*
Mom/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dad/Guardian Name*

First NameLast Name
Dad/Guardian Cell Phone*
Dad/Guardian Address*

Street Address

CityState / Province

Postal / Zip Code
Insurance Carrier*
Insurance Policy Number*
Preferred Hospital*
In the event that the parent/guardian can not be contacted, please contact
Emergency Contact Name (not parent/guardian)*

First NameLast Name
Emergency Contact's Cell Phone*
Relationship to child*
Preferred Physician*
Physician's Phone Number*
I hereby give my consent for medical treatment deemed necessary by physicians designated by school authorities and/or for transportation to a hospital emergency room for treatment for any illness or injury. I understand that this authorization will only be enforced when I can not personally be contacted and provide immediate treatment. Every effort will be made to contact the parent/guardian in the event of an emergency. If we are unable to contact the parent/guardian, emergency rescue will be called.
Signature
AUTHORIZED PICK UP LIST

Please list ALL people who will be permitted to pick your child up this school year. This should include carpool arrangements and any people that will be in contact with your child during the day other than their teacher (ie nanny, grandparents, therapists)
Authorized Person #1*

First NameLast Name
Authorized Person #1 Relationship*
Authorized Person #1 Phone Number*
Authorized Person #2

First NameLast Name
Authorized Person #2 Relationship
Authorized Person #2 Phone Number
Authorized Person #3

First NameLast Name
Authorized Person #3 Relationship
Authorized Person #3 Phone Number
Authorized Person #4

First NameLast Name
Authorized Person #4 Relationship
Authorized Person #4 Phone Number
Custody Information
The safety and well-being of our students and staff is always our priority. To ensure the protection of all our students, staff and teachers, we request a copy of family custody agreements to keep in our records.
YesNoN/A
If there are any special circumstances, information or custody disputes including details if a specific person is NOT legally permitted to pick up your child(ren), please use this box to provide any details below.
Parent Handbook Acknowledgment
I acknowledge
Media Permission

Diocese of Raleigh
Local Media

Local media frequently want to interview students to add a personal touch to stories. Students’ comments may be used in newspapers, publications, web-based outlets, or broadcast on radio or TV. The school system monitors these presentations to ensure that they may reflect positively on the children involved. You will be informed if your child is interviewed by the media. This form allows you as a parent or guardian to choose whether your child may be interviewed.
I give permission to the news media to interview my child. Further, I authorize its use without inspecting or approving the finished product or its specific use.I do not give permission for my child to be interviewed by the news media.
School Social Media

I understand that my child’s photograph may be published on the St. Francis of Assisi Preschool website, social media accounts for St. Francis of Assisi Preschool.
I give my permission for my child’s photo on St. Francis of Assisi Preschool social mediaI do not give permission to put my child’s photo on St. Francis of Assisi Preschool social
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Back to School Form

Emergency Authorization and Information

In the event that the parent/guardian can not be contacted, please contact

AUTHORIZED PICK UP LIST

Custody Information

Parent Handbook Acknowledgment

Media Permission