Back to School Form 2026-2027

Back to School Form

2026-2027
Name of Person Submitting Form:

First NameLast Name
E-mail

Confirmation Emailexample@example.com
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
Any allergies?
List allergies
Any medication being taken?
Medications
Medical condition we should know about?
Medical Condition
Mom/Guardian Name

First NameLast Name
Mom/Guardian Cell Phone
Format: (000) 000-0000.
Mom/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dad/Guardian Name

First NameLast Name
Dad/Guardian Cell Phone
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Relationship to child
Preferred Physician
Physician's Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Authorized Person #2

First NameLast Name
Authorized Person #2 Relationship
Authorized Person #2 Phone Number
Format: (000) 000-0000.
Authorized Person #3

First NameLast Name
Authorized Person #3 Relationship
Authorized Person #3 Phone Number
Format: (000) 000-0000.
Authorized Person #4

First NameLast Name
Authorized Person #4 Relationship
Authorized Person #4 Phone Number
Format: (000) 000-0000.
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?
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.
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
Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
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.
PLEASE CHECK ONE
Media Permission
School Social Media & Publications

I understand that my child’s photograph and/or video may be used by St. Francis of Assisi Preschool for display on the lobby TV, website, social media (Facebook, Instagram), print publications, and other marketing materials. It may also be used for the Saint Francis of Assisi Parish webiste, social media, print publications and other marketing materials. Student names will not be used.
Please Check ONE
Teacher Blogs / Private Shared Sites

I understand that my child’s photograph may be shared on St. Francis of Assisi Preschool’s private teacher blogs/classroom shared sites (accessible only to enrolled families).
Please check ONE
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.
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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

Text Alert System

School Directory

Media Permission

Diocese of Raleigh