HS-EHS Intake Packet English | Family Development Services

Emergency Information & Authorization for Release Card

Child's Name*

First Middle Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Change of Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Change

Parental Status*

One Parent
Two Parents

Primary Parent/Guardian Name*

First Middle Last

Primary Phone Number*

Secondary Phone Number

Email*

Change of Phone Number

Date of Change

Primary Phone Number

Secondary Phone Number

Second Parent/Guardian Name*

First Middle Last

Primary Phone Number*

Secondary Phone Number

Email*

Change of Phone Number

Date of Change

Primary Phone Number

Secondary Phone Number

Health Insurance Name*

Policy/Medicaid #*

Child's Allergies*

Health Concerns/Accommodations*

Daily Medications*

In case of an accident or emergency contact:

Doctor/Clinic*

Phone*

In case of an accident or emergency please take my child to (Hospital)*

*

Family Development Services has my authorization to provide transportation and obtain medical treatment for my child in the event of a medical, health, or building emergency.

*

I provide permission for my child to participate in extracurricular activities/events at the child care center on and off the premises.

Signature of Parent/Guardian*

Date*

The following persons are authorized to pick-up my child from the classroom. Please include parent/guardians on this pick up list. Photo Identification is required for release of child.

*

First & Last Name	Phone	Relationship to Child	Can this person seek Medical Care for my child?	Date of Removal from Pick-up List

*

I understand I am the only one who can make changes to this list, and any changes made must be by me and completed in person.

*

I authorize anyone on this list who is a minor between the ages of 14-17 to receive my child from the classroom pending showing a valid photo I.D.

Signature of Parent/Guardian*

Date*

English Enrollment Form

Step 1 of 9

Family Engagement Contract

Emergency Information & Authorization for Release Card

Income Verification Statement

Asthma Screening Tool

Asthma Screening Confirmation Sheet

Consent for Services

Authorization for Release and Receipt of Child Records

Special Dietary Needs Form

Part 1

Part 2

Part 3

HOME SCHOOL CONNECTION AGREEMENT

Acknowledgement of Receipt of the 2020-2021 Family Handbook and Annual Notice