PERMISSION FORM

Medical Release
This signature certifies the bearer of the document has my permission to authorize necessary emergency
medical care for my child _______________________________. I accept financial responsibility for
necessary treatment and services. I understand that a conscientious effort will be made to contact parents
or guardian and the childs regular physician, if appropriate, before such action is taken.
Date: _____________________ Signature: _______________________________ Relationship to Child:
___________________________________
Parents daytime phone numbers: ________________________________________________
Persons to contact if parents cant be reached:
1) Name: ________________________________________ Phone: _______________________
2) Name: ________________________________________ Phone: _______________________
Childs Physician: ________________________________ Phone: _______________________
Medical Concerns or Allergies: ___________________________________________________
_____________________________________________________________________

PERMISSION TO PHOTOGRAPH
I give permission for my child to be photographed in scheduled preschool activities. Such photographs may
be us by the cooperative for publicity or educational purposes.
Sign if YES

Signature: ______________________________________