Student Information & Medical Release Form - MBPC Preschool Summer Fun 2017
Please complete this form only if you are NOT currently enrolled in our preschool program.

By entering your email address below, you will receive your submitted responses via email. This email will also be used for Summer Fun reminder, notices, etc.

Email address *
Student Information
Child's Full Name: *
Your answer
Name Child is Known By: *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Parent/Guardian Names: *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Home Phone Number: *
Your answer
Mother's Cell Number: *
Your answer
Mother's Employer Telephone Number:
Your answer
Father's Cell Number: *
Your answer
Father's Employer Phone Number:
Your answer
Emergency Contacts
People to contact in case of illness/emergency if parent cannot be reached.
List in order of preference:
#1 Emergency Contact Name: *
Your answer
#1 Emergency Contact Relationship: *
Your answer
#1 Emergency Contact Home Phone Number: *
Your answer
#1 Emergency Contact Home Cell Number: *
Your answer
#2 Emergency Contact Name:
Your answer
#2 Emergency Contact Relationship:
Your answer
#2 Emergency Contact Home Phone Number:
Your answer
#2 Emergency Contact Home Cell Number:
Your answer
#3 Emergency Contact Name:
Your answer
#3 Emergency Contact Relationship:
Your answer
#3 Emergency Contact Home Phone Number:
Your answer
#3 Emergency Contact Home Cell Number:
Your answer
Authorization to Release Child
It is MBPC Preschol's policy that if a child is to be picked up by someone not on the 'child release' section on your child's admission record, the parent MUST PROVIDE WRITTEN AUTHORIZATION (note or email) of the date and name of the person picking up the child. A photo I.D. is required for anyone we do not know that will be picking up your child. We will not release children to an unauthorized person.
1. Name:
Your answer
1. Relationship:
Your answer
1. Home Phone number:
Your answer
1. Cell Phone number:
Your answer
2. Name:
Your answer
2. Relationship:
Your answer
2. Home Phone number:
Your answer
2. Cell Phone number:
Your answer
3. Name:
Your answer
3. Relationship:
Your answer
3. Home Phone number:
Your answer
3. Cell Phone number:
Your answer
Authorization to Photograph Child
During the school year, we may take pictures of the children on our preschool during classroom activities and celebrations. Please check the appropriate boxes to give permission to take and/or publish pictures:
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