Back to School Form 2025-2026

Back to School Form

2025-2026
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

Clear
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.
Do you have a custody agreement?*

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 have read the parent handbook and snack policy and agree to adhere to the policies stated within.*

I acknowledge
Text Alert System

Talking Points
The preschool uses Talking Points to send important alerts and reminders, such as weather-related closures, changes to parking or pickup procedures due to campus events, or emergencies.

You will be automatically enrolled in Talking Points. Please provide the cell phone number(s) where you would like to receive these messages.
Name*

First NameLast Name
Cell Phone*

Area CodePhone Number
Name

First NameLast Name
Phone Number

Area CodePhone Number
School Directory
The preschool shares a class directory to help families stay connected.
This directory allows room parents to communicate with families about school events, social gatherings, and birthday parties.

Please indicate below whether you would like to be included.
If you choose to opt out, you may miss important updates about class activities.
Your information will only be used for school-related purposes and will not be shared outside the preschool community.
I give my permission for my name, phone number and email address to be distributed in the school and class directory.I do not give permission my name, phone number and email address to be distributed in the school and class directory.
Media Permission
School Social Media

I understand that my child’s photograph may be published on St. Francis of Assisi Preschool and St. Francis of Assisi websites, Facebook, Instagram, print publications and marketing materials. Names of students will never be used.
I give my permission for my child’s photo be published on St. Francis of Assisi Preschool and St. Francis of Assisi websites, Facebook, Instagram, print publications and marketing materials. Names of students will never be used.I do not give permission for my child’s photo be published on St. Francis of Assisi Preschool and St. Francis of Assisi websites, Facebook, Instagram, print publications and marketing materials. Names of students will never be used.
Permission is given to use photos of my child(ren) on the St. Francis of Assisi private teacher blogs/shared sitesI do not give permission is given to use photos of my child(ren) on the St. Francis of Assisi private teacher blogs/shared sites
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 for the Diocese of Raleigh.I do not give permission for my child to be interviewed by the news media.
Enter the message as it's shown*
Should be Empty:

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

Text Alert System

School Directory

Media Permission

Diocese of Raleigh