General Release Form GENERAL RELEASE FORM STUDENT(S) INFORMATIONChild'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 knowList any medications your child takes regularlyPhysician's Name(Required)Physician's Phone(Required)Additional Student Add a sibling in another classChild #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 knowList any medications your child takes regularlyPhysician's Name(Required)Physician's Phone(Required)Health Insurance Provider(Required)Group Number(Required)PARENT/GUARDIAN INFORMATIONPer 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 - Cell Phone(Required)Parent/Guardian #1 - Work PhoneParent #1 - Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does Parent/Guardian #1 share legal responsibility for the child with another Parent/Guardian?(Required) Yes No Parent/Guardian #2 Name(Required) First Last Parent/Guardian #2 - Cell Phone(Required)Parent/Guardian #2 - Work PhoneDoes Parent/Guardian #2 reside at the same address as Parent/Guardian #1?(Required) Yes No Parent #2 - Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EMERGENCY CONTACT INFORMATIONEmergency 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)PhoneName(Required) First Last Relationship to child(Required)Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)PhoneADD ADDITIONAL INDIVIDUALS AUTHORIZED TO PICK UP YOUR CHILDIndividuals 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)PhonePIck Up Person #2 Add another pick up personName(Required) First Last Relationship to child(Required)ADDRESS(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)PhonePIck Up Person #3 Add another pick up personName(Required) First Last Relationship to child(Required)ADDRESS(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Phonepick up person 4 Add another pick up personName(Required) First Last Relationship to child(Required)ADDRESS(Required) Street Address City State / Province / Region ZIP / Postal Code PHONE(Required)PHONEParent/Guardian AgreementsEmergency 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 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)SMS Text(Required) I understand that Cherry Preschool may periodically use an automated system to deliver informational messages to the mobile numbers provided for parents/guardians. (e.g., school closure)(Required)Photo Release Class News I give permission for Cherry Preschool to use photographs or videos of my child in weekly newsletters to be distributed only to my child's class.Photo Release Marketing/Social Media I give permission for Cherry Preschool to use photographs or videos of my child for marketing purposes, on our website, or on social media (Facebook, Instagram). I understand that my child will receive no compensation and will not be identified by name.I give permission for Cherry Preschool to list the following family information in the School Directory. This information will not be sold/shared with anyone outside of the preschool. Address Parent/Guardian Cell Phone Numbers Parent/Guardian Email Addresses Parent/Guardian Signature(Required)Date(Required) MM slash DD slash YYYY Δ
