Student Record & Release Form

CHILD INFORMATION

Child's Name

First NameLast Name

Date of Birth

MonthDayYear

Home Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

Area CodePhone Number

PARENT INFORMATION

Parent 1 Name

First NameLast Name

Parent 1 Cell

Area CodePhone Number

Parent 1 E-mail

Parent 1 Occupation

Parent 1 Firm

Parent 1 Work Phone

Area CodePhone Number

Parent 2 Name

First NameLast Name

Parent 2 Cell

Area CodePhone Number

Parent 2 E-mail

Parent 2 Occupation

Parent 2 Firm

Parent 2 Work Phone

Area CodePhone Number

SIBLING INFORMATION

Sibling's Name

Date of Birth

MonthDayYear

Sibling's Name

Date of Birth

MonthDayYear

Sibling's Name

Date of Birth

MonthDayYear

Sibling's Name

Date of Birth

MonthDayYear

GRANDPARENT INFORMATION

Grandparents' NamesMaternal

Grandparents' AddressMaternal

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Grandparents' E-mailMaternal

Grandparents' NamesPaternal

Grandparents' AddressPaternal

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Grandparents' E-mailPaternal

MEDICAL INFORMATION

Doctor's Name

Doctor's Phone Number

Area CodePhone Number

Please indicate any allergies or medical conditions the school should be aware of:

EMERGENCY CONTACT INFORMATION

Emergency Contact #1 Name

Phone Number

Area CodePhone Number

Emergency Contact #2 Name

Phone Number

Area CodePhone Number

Dismissal Procedures

1. In order to take every possible safety measure at dismissal, we require that each person, othan than a parent, authorized to pick up your child be known to your child's teacher and to the director. In the event that someone not listed below will be picking up your child, please call the school with the individual's name and physical description.

Caregiver Name

Phone Number

Area CodePhone Number

2. In the event that your child is not picked up from school and we are unable to notify you or any of the contacts, we will call another parent from the school to take your child to their home until you are contacted. Please indicate two other parents (preferably parents of your child's friends) with whom we may leave your child.

OELC Parent Contact #1

OELC Parent Contact #2

Releases

TRIPS
For the school year September 2019 - June 2020: I hereby give my child permission to go on walking trips in the neighborhood and on the trips via school bus or public transportation. I understand that I will receive notification of upcoming trips through the school calendar or email. I further understand that the children may go on walking trips in the neighborhood without prior notification.

Electronic Parent Signature

Today's Date

MonthDayYear

EMERGENCY POLICY
In case of a medical emergency, G-d Forbid, the school will call Hatzalah. If the Emergency Responders decide that the situation warrants swift medical attention, your child will be taken to the nearest hospital together with his/her medical file. Parents will be immediately notified. Until a parent is reached, the director or teacher will be in charge and make all decisions about the care of your child. In all non-emergency situations, the parents will be contacted. If parents cannot be reached, we will contact your pediatrition and follow instructions. In situations where your child must be taken home and you cannot be reached, we will contact the people indicated above. By signing this form, you also consent to assume any and all fiscal responsibilities incurred by the school in the course of your child's medical emergency.
I hereby authorize the Osher Early Learning Center to obtain necessary medical treatment for my child in accordance with the above mentioned Emergency Policy.

Electronic Parent Signature

Today's Date

MonthDayYear

SUNSCREEN, ANTISEPTIC & DIAPER CREAM
For the school year September 2019 - June 2020, I hereby give permission to the staff of the Osher Early Learning Center to apply topical over-the-counter creams to my child according to label instructions.

Electronic Parent Signature

Today's Date

MonthDayYear

MEDIA RELEASE
For the school year September 2019 - June 2020, I hereby give the Osher Early Learning Center permission to use my child's likeness for publicity purposes to help promote their program.

Electronic Parent Signature

Today's Date

MonthDayYear