Visit our Facebook
200 Riverside Avenue, Riverside, CT 06878
St. Paul's Church
Child's Full Name
Address Line 2
State / Province / Region
ZIP / Postal Code
Primary Parent's Full Name
Primary Parent's Contact Number
Primary Parent's Email
Secondary Parent's Full Name
Secondary Parent's Contact Number
Secondary Parent's Email
What allergies does your child have?
Is your child taking any medication(s) on a regular basis? If so, please list.
Does your child have any illness that a physician should be aware of? (i.e., seizures, heart problems, diabetes, asthma). If so, please list.
I authorize any licensed physician to provide any proper emergency treatment in the event of an emergency with my child. I understand that this authorization is given prior to any need for medical care and is given to avoid any unnecessary delay for emergency treatment which the physician may deem advisable in the exercise of his/her best judgement. I assume a reasonable attempt will be made to contact me. I also authorize ST. PAUL'S PAY SCHOOL to arrange for emergency transportation away from the school program to the nearest medical facility. I also authorize First Aid Treatment from trained staff members.
I authorize the above terms.
I UNDERSTAND AND AGREE TO THE AFOREMENTIONED PROCEDURES:
The following individuals have permission to transport my child from the school program in my absence:
Please list any relevant medical professionals you want on record for your child.
Your child's primary Doctor and Dentist are required.
My child has my permission to accompany his/her nursery school class on special field trips. I understand that my child's teacher will notify me of the exact date, time, and place prior to each projected class trip.
I understand and agree to the aforementioned procedures.