Pixie Hill Forms 2024-25

Child's Name

First NameLast Name
Contact Information
Child's Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact

First NameLast Name
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email
example@example.com
Secondary Contact

First NameLast Name
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Email
example@example.com
Additional Contacts in Case of Emergency
Name, Phone Number and Relation
Would you like both emails above on our distribution list or just the primary email?
Is there any other email you'd like on the distribution list?
List email addresses
Do you consent to including your contact email on a class roster to only be shared with Pixie Hill families?

Medical Authorization Form
Please list any medications your child may require during school and reason for taking it.
Type of medication

Other
Requires refrigeration
Start Date

MonthDayYear
Date
Stop Date

MonthDayYear
Date
Time to be administered
Amount to be administered
Possible side effects
Additional special instructions
Parent/Guardian Signature
Physician Signature
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Media Image - Release Form
I, Parent Name*, permit or deny permission to Pixie Hill Preschool to use the image of my child, Child Name* as indicated by my selection below.

Such use includes the display, distribution, publication, transmission or otherwise use of photographs, images and/or video taken of my child for the use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images.
I grant permission to use my image in the following:

Unrestricted usage: I give unrestricted permission for my child's image to be used in print, video and digital media. I agree that these images may be used by Pixie Hill for a variety of purposes (including our website and private photo sharing account) and may be used without further notifying me. I do understand that my child's name will *not* be used in conjunction with any video or digital images.
Parent/Guardian Signature

Student Pick-up Information
The following will be my child's primary pickup person

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to student
Other people who I authorize to pick up my child
Name, phone number and relationship to student
Please let us know if this changes at any time during the school year. Unfamiliar people will be asked to show ID.
Signature
Should be Empty:

Contact Information