Student Information for Attending Pre School and Toddler Classes
PICK UP INFORMATION
To ensure the safety of your child please provide Adirondack Enrichment with the names and contact information of any individuals who you give consent for picking up your child.
We cannot release any child to a person that is not on this list unless we receive a phone call from a parent/guardian and the person picking up your child shows identification.
Child Information
Child's First Name:
Child's Last Name:
Child's Date of Birth:
Gender
Male
Female
Parent/Guardian Information
Parent/Guardian First Name:
Parent/Guardian Last Name:
Cell Phone #:
Home Phone #:
E-mail:
The following people have permission to pick up my child who is not the parent/guardian:
Persons able to pick up my child:
First Name:
Last Name:
Cell Phone #:
Relationship to child:
EMERGENCY INFORMATION
In the event a parent/guardian or an emergency contact person cannot be reached, and an accident or injury occurs, I authorize any and all emergency medical, dental, and/or surgical care and hospitalization advised by the physicians, surgeon, or hospital on file necessary for the proper health and well-being of my child:
Emergency Contacts:
First Name:
Last Name:
Cell Phone #:
Relationship to child:
ALLERGY/MEDICATIONS INFORMATION
Does your child have any allergies:
Yes
No
What allergies does your child have:
Seasonal
Food
Medications
Other
Other Medications:
Does your child take medications for their allergies?
Yes
No
What medication?
How often?
Daily
As needed
Other
Other:
Does your child require an epi pen?
Yes
No
Please give in detail any information we need to know about your child's allergies:
PICTURE RELEASE
I agree to my child's picture being taken for the following:
School Projects
Social Media (Facebook)
Publications (Adk website)
Name of Person Filling Out Form:
Relationship to Child:
Please select...
Mother
Father
Grandparent
Guardian
Other
Other:
Date:
Contact Information