CHILD’S NAME_____________________________________________________

FIELD TRIP PERMISSION:

I GIVE MY CHILD PERMISSION TO PARTICIPATE ON FIELD TRIPS WITH DOLLY’S NURSERY SCHOOL:

YES / NO

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PHOTOGRAPH PERMISSION:

I GIVE DOLLY’S NURSERY SCHOOL PERMISSION TO INCLUDE MY CHILD IN PHOTOGRAPHS TAKEN DURING SCHOOL:

YES / NO

I GIVE DOLLY’S NURSERY SCHOOL PERMISSION TO HAVE PHOTOGRAPHS TAKEN AT SCHOOL SENT TO LOCAL NEWSPAPERS FOR PRINTING:

YES / NO

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SCREENING PERMISSION:

I GIVE DOLLY’S NURSERY SCHOOL PERMISSION TO INCLUDE MY CHILD IN SCREENINGS FOR HEARING, SPEECH, SIGHT, AND LAZY EYE. DATES AND TIMES WILL BE ANNOUNCED PRIOR TO THE SCREENINGS:

YES / NO

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AUTHORIZATION AND CONSENT:

I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT ME IN THE EVENT OF AN EMERGENCY REQUIRING MEDICAL ATTENTION FOR MY CHILD. HOWEVER , IF I CANNOT BE REACHED, I HEREBY GIVE DOLLY’S NURSERY SCHOOL PERMISSION TO PROVIDE FIRST AID BY CERTIFIED STAFF OR IF NECESSARY CONTACT MY CHILD’S PEDIATRICIAN OR IF NECESSARY SUMMON EMERGENCY MEDICAL SERVICES TO TRANSPORT MY CHILD TO SOUTH SHORE HOSPITAL.

YES / NO

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PARENT’S SIGNATURE

_________________________________________________

DATE ___________________

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PLEASE LIST ANY PEOPLE (OTHER THAN PARENTS) WHO ARE AUTHORIZED TO PICK UP YOUR CHILD.

NAME_____________________________________________

ADDRESS_________________________________

RELATIONSHIP_____________________________________

TELEPHONE #____________________________

MORE NAMES MAY BE LISTED ON THE BACK OF THIS FORM.