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General Release Form

GENERAL RELEASE FORM

STUDENT(S) INFORMATION

Child's Full Name(Required)

First Last

Child's Birthdate(Required)

MM slash DD slash YYYY

Note any medical condition/allergies your child has that an emergency health care worker should know

List any medications your child takes regularly

Physician's Name(Required)

Physician's Phone(Required)

Additional Student

Add a sibling in another class

Child #2 Full Name(Required)

First Last

Child #2 Birthdate(Required)

MM slash DD slash YYYY

Note any medical condition/allergies your child has that an emergency health care worker should know

List any medications your child takes regularly

Physician's Name(Required)

Physician's Phone(Required)

Health Insurance Provider(Required)

Group Number(Required)

PARENT/GUARDIAN INFORMATION

Per DCFS regulations, each parent/guardian must be listed on the General Release form to be authorized to pick up their child from school.

Parent/Guardian #1 Name(Required)

First Last

Parent/Guardian #1 Phone(Required)

Parent/Guardian #1 Phone

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Phone

Same Address

Same address

Address

Street Address City State / Province / Region ZIP / Postal Code

EMERGENCY CONTACT INFORMATION

Emergency contacts must be someone other than a parent/guardian.

In case of an emergency, when neither parent/guardian can be reached, please call the following people (in this order). These individuals are authorized to pick up my child.(Required)

In case of an emergency, when neither parent/guardian can be reached, I consent to have Cherry Preschool call the following people (in this order). These individuals are authorized to pick up my child.(Required)

Name(Required)

First Last

Relationship to child(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Phone

Name(Required)

First Last

Relationship to child(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Phone

ADD ADDITIONAL INDIVIDUALS AUTHORIZED TO PICK UP YOUR CHILD

Individuals must be at least 18 years of age to pick up a child from preschool per DCFS regulations. Staff may request identification if the person picking up your child is unknown to them.

Authorize PU Person

Check here to authorize and add an individual to your child's pick up list.

Name(Required)

First Last

Relationship to child(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Phone

PIck Up Person #2

Add another pick up person

Name(Required)

First Last

Relationship to child(Required)

ADDRESS(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Phone

PIck Up Person #3

Add another pick up person

Name(Required)

First Last

Relationship to child(Required)

ADDRESS(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Phone

pick up person 4

Add another pick up person

Name(Required)

First Last

Relationship to child(Required)

ADDRESS(Required)

Street Address City State / Province / Region ZIP / Postal Code

PHONE(Required)

PHONE

Parent/Guardian Agreements

Emergency Care(Required)

If emergency care is indicated and I am not immediately available, I authorize Cherry Preschool to call the paramedics to take my child to Evanston/St. Francis Hospital for treatment.(Required)

Parent Handbook(Required)

I certify that I have been provided a copy of and read Cherry's Covid Policies and Parent Handbook, including the summary of licensing standards printed by the Illinois Department of Children and Family Services.(Required)

Neighborhood Walks(Required)

I agree that my child may be taken on neighborhood walks under the supervision of their teachers. ( e.g., Penny Park, nature walks)(Required)

Email(Required)

I understand that Cherry Preschool will use my e-mail address for school related communications and emergency notifications. I understand that it will not be sold to/shared with anyone outside of the preschool.(Required)