Address

City State Zip Code

Phone Numbers

Child's Birthday

Mother's Name & Address (if different)

Father's Name & Address (if different)

Parent's/Guardian's E-mail Address

Physician's Name & Phone Number

Preferred Dentist & Phone Number

Please list the following: Any allergies/medications your child is allergic to; Medications your child is taking;
Physical or mental conditions; Illnesses or chronic conditions; Or anything else the school should be aware of
in regard to your child . . .

Is there anything that your child may not have as a snack or drink?

Is there any activity that your child should not engage in?

Please list the adults who are allowed to pick up your child . . .
(If the above listed person is picking up your child, please send a note prior to the pick up stating who will be
picking your child up and what the date of pick up will be.)

In case of emergency contact

Phone Number

Relationship to child

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I give my consent for the Spring Hill Church of Christ Tuesday School staff to provide emergency treatment for
my child in the event of an accident, injury, or serious health condition occurring while at the school. Every attempt
will be made to contact the parent, as well as the preferred doctor or dentist. If contact to a parent, guardian, or
emergency contact cannot be made, child will be transported to Middletown Regional Hospital for emergency
treatment at your expense for the treatment.

Agree
Disagree

Name of Parent or Guardian Filling Out Form Date

OR

I DO NOT give my consent to provide any emergency treatment to my child. I understand that I or my child's
emergency contact will be contacted and asked what treatment, if any, is to be administered in the event of an
accident, injury, or serious health condition arising while at the school.

Agree
Disagree

Name of Parent or Guardian Filling Out Form Date

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All finished? Then please hit the Submit Button! - - -