Jan`s Show `N Tell Preschool

Jan's Show 'N Tell Preschool
EMERGENCY MEDICAL AUTHORIZATION
PERMISSION FOR FIELD TRIPS
(This form needs t o be notarized)
lNVe being the natural or legal guardian of
do hereby authorize Jan's Show 'N Tell Preschool to obtain any and all medical
attention or services and hospitalization. I understand that in case of an accident or
injury to my child and preferred hospital to be used are as follows:
Doctor:
Telephone:
Preferred Hospital:
Telephone:
It is understood and agreed that I will be responsible for any such debts incurred
on behalf of my child, and I agree to hold Jan's Show 'N Tell Preschool harmless from
any and all liability for any such debt incurred.
Signature
STATE OF MISSOURI)
) ss.
COUNTY OF CLAY )
Subscribed and sworn to before me this
,
day of
Notary Public
My Commission Expires:
has permission to attend
My Child,
all of the field trips involving Jan's Show 'N Tell Preschool. We will be notified at least
one day in advance.
Signature
Teacher: Jan Covey
Jan's Show 'N Tell Preschool
Excelsior Springs, MO 64024
..:.
,
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MISSOURI DEPAFTMENT OF HEALTH
BUREAU OF CHILD CARE SAFETY & LiCENSURE
1 BlRTFfDATE
I
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i
I
II. CURRENT STATE OF HEALTH
I HAVE EXAMINEDTHE ABOVE-NAMED CHILD AND VERIFY THATTHIS CHILD'S MEDICAL HISTORY AND CURRENT STATE CF HEAL*
4
a ARE a ARE NOT
SATISFACMRY FOR PARTICIPATION IN A CHILD CARE PROGRAM.
DOES THIS CHILD REQUIRE ANY SPEClALlZED CARE?
YES
NO
IFYES, EXPLAIN IN SECTION IV.
Ill. IMMUNIZATION HlSTORY
OUR RECORDS INDICATE THAT THIS CHILD HAS THE FOLLOWING IMMUNIZATIONS:
DATES GIVEN
IMMUNIZATIONS
I Dose No. 1 . Dose No. 2
Cose No. 3 ! Dose No.4
r
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I
1
1
I
Dose No. 5
1
Dose No, 6
I
(SPECIAL DIETS, ALLERGIES, EAR INFECTIONS, CONVULSIONS, DIABETES. EMOTIONAL PROBLEMS)
SIGNATURE OF PHYSICIAN OR REdlSTEREO NURSE
UNOER THE SUPERVISION OF A PHYSlClAN
DATE
D
b
IF NURSE IS SUPERVISED BY ?HYSICIAN. INMCbTE PHYSICIAN'S W
NAME OF CLINIC. GROUP PRACTICE. O M E R
E
I
I
I
/ ADDRESS (STREET, cm, STATE,ZP CODE)
1
MO m.ie7a 14-97)
j TELEPHONE NUMBEH
THIS REPORT 13 TO BE KEPT ON FILE AT THE CHILD CARE F A C : m
Lx
Jan's Show 'N Tell Preschool
1500 Roselea
Excelsior Springs, Mo . 64024
816-878-1227
Policies and Procedures
In order to assure that parents clearly understand the procedures and policies of Jan's Show 'N Tell
Preschool, we ask all parents to read the policies enclosed with the application packet and also to check
off the following items:
1. Parents are responsible for payment of fees on time. A late fee of twenty ($20.00) will be added
to bills not paid on the due date. If tuition is not paid by the 10"' of the month. your child will be
withdrawn from the preschool program. A new registration fee will be required in order to
reinstate your child in the preschool program.
2. There is no reduction of fees for absences or vacations, etc.
-3.
I understand that I must walk into the building with my child each day and make certain the
teacher knows helshe is there.
4
. I give my consent for my child to attend all field trips involving Jan's Show 'N Tell Preschool. If 1
do not drive, my child has permission to ride in another child's car secured with a seat belt.
5
. Keep child home with the following: fever. diarrhea. vomiting in previous 24 hour period.
Children too sick to participate in the full preschool program need to be kept home.
6. Parents need to inform the preschool of changes in addresses, phone number, employment.
emergency information or any changes in family situations.
7
. Parent is expected to pick-up children at dismissal time or 1 1 : 15 a.m.
8
. The Preschool Director is to be notified two (2) weeks in advance before a child is to be
withdrawn. Parents are required to pay for those two (2) week regardless of when child stops
attending classes.
9
. If after a reasonable period of time it is found that a child is unable to adjust to the preschool. the
preschool reserves the right to request withdrawal of the child. This decision is left to the
discretion of the director and teachers. (We allow a minimum adjustment period of two (2)
weeks.)
10. I agree to abide by these rules and regulations.
Signature of ParentIGuardian
Jan's Show 'N Tell Preschool
1500 Roselea
Excelsior Springs, Mo . 64024
THOSE AUTHORIZED TO PICK UP CHILD
CHILD'S NAME:
CLASS: (Please circle class your child attends)
Mon-Wed-Fri
DISMISSAL
The following people are authorized to pick up my child up from Show 'N Tell Preschool:
Name
Relationship
Phone
Name
Cell Phone
Relationship
Phone
Name
Cell Phone
Relationship
Phone
Name
Cell Phone
Relationship
Phone
Cell Phone
The authorized people you have listed should be told your child's number that has
been assigned to himlher. If at any time we are in doubt as to who is picking your child
up from preschool, your child will NOT be released until we contact a parent. We want
to keep your child safe so we appreciate your cooperation with dismissal.
Please return this form to the teachers to place in your child's file.