Child's Name:
Date of Birth:
Age as of Sept. 1:
Child's Address:
City & Zip Code:
Home Phone:
Parent E-mail:
Father's Name:
Father's Employer:
Father's Work Phone:
Father's Cell Phone:
Mother's Name:
Mother's Employer:
Mother's Work Phone:
Mother's Cell Phone:
Emergency Contact:
Relationship:
Emergency Phone:
Emergency Cell Phone:
I authorize Rainbow School to allow my child to leave the preschool facility ONLY with the following persons.
List any additional information that we need to know concerning your child, such as allergies, existing illness, previous serious illness, injuries during the past 12 months, any medication prescribed for long term continuous use, or special needs we should be aware of:
AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:
In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to:
Name of Physician:
Address:
Phone:
Hospital/Clinic Preference:
Address:
Phone:
I give consent for necessary emergency treatment when my child is in the care of this physician and/or hospital / clinic.
Parent Name:
Date:
Family Church Affiliation:
How did you learn about Rainbow School:
