FIRST AID/EMERGENCY CARE AND PERMISSION FORM


CHILD'S NAME_________________________________________________________________________


DATE OF BIRTH_____________________________________


FUND RAISING ACTIVITIES: Dolly's PTAB holds three fund raising events each year. I give Dolly's permission to include me in the events:
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
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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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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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CHILD'S PEDIATRICIAN _________________________________

TELEPHONE #________________________

HEALTH INSURANCE COVERAGE_____________________________________

POLICY #____________________

ALLERGIES/CHRONIC HEALTH CONDITIONS_______________________________________________________________________
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THREE EMERGENCY CONTACT PEOPLE (OTHER THAN PARENTS) WHO ARE AUTHORIZED TO PICK UP YOUR CHILD.

NAME________________________________________________

ADDRESS_________________________________

RELATIONSHIP________________________________________

TELEPHONE #____________________________

CELL TELEPHONE #____________________________
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NAME________________________________________________

ADDRESS_________________________________

RELATIONSHIP________________________________________

TELEPHONE #____________________________

CELL TELEPHONE #____________________________

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NAME________________________________________________

ADDRESS_________________________________

RELATIONSHIP________________________________________

TELEPHONE #____________________________

CELL TELEPHONE #____________________________
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PARENT’S SIGNATURE_________________________________________________

DATE ___________________
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This form must be updated and re-submitted each year.