2024-25 Living Hope Preschool Application Form

Living Hope Preschool Parental Emergency Medical Consent 2024-2025

Living Hope Preschool
Child #1 Name*

First NameLast Name
Child #2 Name

First NameLast Name
Medical Insurance Company*
Policy Holder's ID*
Preferred Hospital*
Child's Doctor*
Doctors Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance Company (Type None if no insurance)*
Policy Holder's ID (Type None if no insurance)*
Preferred Dentist Office *
Family Dentist*
Dentist's Phone Number*

Area CodePhone Number
Dentist's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In the event that my child(ren) (listed above) may require medical and/or surgical care while I am out of the city or unable to be reached. I hereby give my consent to Medical and/or surgical treatment to the above hospital and above doctor or his/her designee to provide this care. In the event that my child(ren) (listed above) may require dental and/or dental surgical care to the above dentist or his/her designee to provide this care. I agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for my child(ren) as secured or authorized under this consent.

Please note: Every effort will be made to notify parents/guardians immediately in case of emergency. This form will be presented upon admission for treatment.
I have read and understand the emergency medical procedures to be folled by Living Hope Preschool staff in the event of an emergency.

I hereby authorize Living Hope Preschool to call an ambulance or paramedic in case of accident or acute illness and to arrange for necessary medical, dental or surgical care in case I am not immedately available. I also agree to accept financial responsibility for the cost of the above mentioned servicer.

It is understood that a conscientous effort will be maded first to contact the parents or guardian and then to contact the responsible adults designated as emergency contacts before such action will be taken.

I further hold harmless Living Hope Bible Church or Living Hope Preschool from any liability regarding the care of my child(ren) while he or she is in their care, custody, or control.

This consent will be in effect while the child(ren) is enrolled in this facility.
Signature*

Clear
Date*

MonthDayYear
Date

Parent/Guardian #1 with Whom the Child(ren) Reside *

First NameLast Name
Relationship to Child(ren)*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Parent/Guardian #2 with Whom the Child(ren) Reside (If applicable)

First NameLast Name
Relationship to Child(ren)
Phone Number

Area CodePhone Number
Employer
Person #1 to Contact if Parents/Guardians are unavailable and are authorized to pick up child(ren)*

First NameLast Name
Relationship to child(ren)*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person #2 to Contact if Parents/Guardians are unavailable and are authorized to pick up child(ren)*

First NameLast Name
Relationship to child(ren)*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are there any custody or restraining orders for person(s) who may attempt to pick up or have contact with the child(ren) while in care at the center?*
If yes - list name(s) below.

First NameLast Name
First NameLast Name

Living Hope Preschool Permission Slip 2024-2025
Child #1 Name*

First NameLast Name
Child #2 Name

First NameLast Name
Field Trips

Throughout the year, your child(ren) will have the opportunity to attend various field trips. Families will be notified prior to these events. Your permission on this form will allow participation for all field trips.
I give permissionI do not give permission
Application of Sunscreen

Occasionally, with outside activities your child(ren) may require sunscreen for protection from the sun. Your permission on this form will give permission for the preschool staff to apply sunscreen as needed.
I give permissionI do not give permission
Pictures

Throughout the year, various pictures of your child(ren) may be taken during class activities, programs, or field trips. Your permission on this form will give permission for Living Hope to display these pictures for promotional purposes and in our monthly newsletter.
I give permissionI do not give permission
Facebook Page & Living Hope Bible Church Website

Living Hope Preschool has a Facebook page and a page on Living Hope Bible Church's website. We would like to post pictures of the children working/playing at school and on our field trips. Please check one box below.
I give permission to post pictures of my child(ren) on Living Hope Preschool's Facebook page and church website.I do not give permission to post pictures of my child(ren) on the Living Hope Preschool Facebook page or church website.
I have read and checked the boxes of the above statements, either granting permission or requesting an exclusion for my child(ren).*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Living Hope Preschool

Living Hope Preschool Parental Emergency Medical Consent 2024-2025

Living Hope Preschool Permission Slip 2024-2025