EAST BUCHANAN PRESCHOOL
CHOOSE YOUR DAY FORM
ALL FORMS MUST BE TURNED IN BY OCTOBER 14, 2016
Student’s Legal Name Birthdate:
Parent/Guardian Information:
Name:
Address:
City, State, Zip:
Home Phone: Email:
Father’s Work Phone: Workplace:
Mother’s Work Phone: Workplace:
Father’s Cell Phone: Mother’s Cell Phone:
Doctor/Hospital Preference:
Doctor/Hospital Phone Number:
PLEASE READ: Every effort will be made to contact you if your child is ill or injured. In the event that we are unable to reach you or the person you designate and it is deemed necessary that your child have emergency treatment, please sign on the line below giving your permission to transport your child (at parent’s expense) to the nearest hospital available.
Parent’s Signature
Please circle the following program and the preferred days of attendance:
3-YEAR-OLD MORNING PROGRAM (Parent Funded)
(Please circle the preferred days of attendance)
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
4-YEAR-OLD HALF DAY PROGRAM (State Funded)
(Please circle the preferred days of attendance)
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
4/5-YEAR-OLD ALL DAY PROGRAM
(4-Year-Old Parent Funded, 5-Year-Old State Funded)
(Please circle the preferred days of attendance)
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
** For scheduling purposes, these days may be changed if needed.
** Wednesdays will only be a half-day for all students.
EAST BUCHANAN PRESCHOOL
PICK-UP FORM
ALL FORMS MUST BE TURNED IN BY OCTOBER 14, 2016
A. The following peoples HAVE permission to pick-up ______from East Buchanan Preschool.
Child’s Name: / DOB: / Age: / Sex:1. Name: Relationship:
Address:
Phone Number:
2. Name: Relationship:
Address:
Phone Number:
3. Name: Relationship:
Address:
Phone Number:
4. Name: Relationship:
Address:
Phone Number:
5. Name: Relationship:
Address:
Phone Number:
B. Is anyone legally restrained from picking up your child? (Please circle) YES NO
**If yes, a copy of a court order must be provided.
EAST BUCHANAN PRESCHOOL
CONSENT FOR NON-PRESCRIPTION MEDICATIONS FORM
ALL FORMS MUST BE TURNED IN BY OCTOBER 14, 2016
CHILD’S NAME DATE AGE
1) I give permission for my child to participate in all scheduled field trips.
2) I give permission for my child’s file to be available for licensing and program review procedures.
3) I give permission for my child to have the following screenings: Speech, Hearing, Vision, Developmental, Dental, Height and Weight, Blood Pressure, Brigance Preschool Screen, and ASQ.
4) I give my permission to East Buchanan Preschool to exchange information with partnering agencies which includes: Department of Human Services, AEA 267 Education Agency, and Buchanan County Health Department. I understand I will be notified if there is a need for further evaluation, follow-up treatment, therapy or counseling. This permission is valid only during the time my child is enrolled.
5) I give permission to be contacted by text messaging or email. Please provide email address:
6) I give permission to use the following items only when needed and according to the directions on the container:
· A & D Ointment
· Hand & Body Lotion
· Sunscreen (as provided by parent)
· Anti-Itch Lotion (Caldyphen)
7) I give permission for my student to be involved in pictures and/or videos that may be placed online (Facebook, Twitter, school website,
etc.).
8) I anticipate my student eating lunch for the 2016-2017 school year.
Signature of Parent/Guardian
(Please Initial)
YES NO
Date
East Buchanan Community Schools
414 5th St. N Winthrop, IA 50682
Phone- (319) 935-3660 Fax- (319) 935-3749
ALL FORMS MUST BE TURNED IN BY OCTOBER 14, 2016
**PARENTS- PLEASE COMPLETE THIS SIDE**
Student
Female Male Date of Birth
MEDICAL AND HEALTH HISTORY
HISTORY / DATE / COMMENTSPrenatal/Birth
Allergies / To Medication ______
To Food ______To Latex ______
Epi-Pen: ☐ Yes ☐ No
Asthma
Medications
Illness, serious
Chickenpox / ☐ Diagnosed / ☐ By Report
Injury, serious
Hospitalization, Surgery
Immunizations
(Attach IRIS Form) / ☐ Up to date for school entry
☐ Boosters needed:
Other
Parent’s Statement on Sharing of Information:
Information on this form is confidential and will be filed in my student’s classroom. I acknowledge that the information noted on this form will be shared with school staff members only on a need-to-know basis for the safety and well-being of my child.
Parent/Guardian Signature:
** THIS SIDE IS TO BE FILLED OUT BY FAMILY PHYSICIAN**
** PLEASE ATTACH IMMUNIZATION FORM TO THIS PHYSICAL FORM
PHYSCIAL EXAM AND ASSESSMENTBy Physician, Nurse Practitioner, or Physician Assistant
Date of Exam: ______
Height ______Weight ______Blood Pressure ______
Vision: Both 20/______Right: 20/______Left: 20/______
SYSTEM / WNL / Comments:
Skin
Eyes / Referred:
Ears/Hearing
Mouth
Speech
Neck
Heart
Lungs
Abdomen
Genitourinary
Musculoskeletal
Spinal / Scoliosis Screening: WNL_____Referred____
Neurologic
Emotional/Social
Lead Screening (Required) / Date: Results:
Labs if indicated
TB Risk / Mantoux if indicated
Health conditions requiring intervention/modification at school:
Physical Education Program: Full______Limited______None______
Reason:
Examined by (print) ______
Signature: ______Date: ______
Clinic: ______Phone: ______