I. Please help us better understand your child.
II. Care Needs
How does your child communicate with others?
Eating Habits:
III. Emergency Contacts (other than doctor)
IN CASE OF AN EMERGENCY, THE FOLLOWING PERSONS MAY BE CALLED AND ARE AUTHORIZED TO PICK UP MY CHILD: (At least one contact must be provided. Positive identification must be provided before your child will be released.)
IV. Permission/Authorization Agreement
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INITIAL IN THE DESIGNATED SPACE INDICATING THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS.
I have read and initialed the above permission/authorization statements and agree to the terms designated in each: