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Preschool Emergency and Permission Form

Preschool Emergency & Permission Form

ALL information on this form is required by the state of Minnesota for licensing.

Step 1 of 5

20%

Child's Name*
First Last
Nickname (if any)
First
Birth Date*
Child's Address*
Street Address City State ZIP Code
Parent / Guardian 1*
First Name Last Name
Parent / Guardian 1 Phone Number*
Parent / Guardian 1 Address*
Same as Child

Street Address City State ZIP Code
Parent / Guardian 1 Email*
Enter Email Confirm Email
Parent / Guardian 1 Information (optional)
Occupation Employer
Parent / Guardian 2
First Name Last Name
Parent / Guardian 2 Phone Number
Parent / Guardian 2 Address
Same as child

Street Address City State ZIP Code
Parent / Guardian 2 Email
Enter Email Confirm Email
Parent / Guardian 2 Information (optional)
Occupation Employer

Emergency Contacts
At least two contacts are required for emergency contact and alternative pickup. Please do not re-enter parent/guardian information for emergency contacts. These are alternative contacts.
ALL FIELDS REQUIRED for emergency contacts.
Emergency Contact 1*
(NOT a parent)
Name Relationship
Emergency Contact 1 Phone*
Emergency Contact 1 Address*
Street Address City State ZIP Code
Emergency Contact 2*
(NOT a parent)
Name Relationship
Emergency Contact 2 Phone*
Emergency Contact 2 Address*
Street Address City State ZIP Code
Additional Emergency Contacts (Optional)
Click the + symbol if you need to add more than one additional contact.
Name Relationship Phone City/ State

Medical and Dental Information
This information is required by our licensing. Please fully complete each section.
Child's Physician Name*
Physician's Name or Group Name
Physician Phone*
Physician Address*
City State
Preferred Hospital*
My Child Has:*
- NO KNOWN allergies, medical needs, or dietary restrictions.
- medical needs or severe allergies that require an Individual Care Plan. (i.e. asthma)
- food intolerances or special dietary needs.
Please describe limitations, care required or appropriate response for any conditions specified above:
Please leave blank if none.
Permission to Alert Staff*
By clicking the box, I agree to allow Dodge Nature Preschool to post a small photo of my child in the classroom and food preparation areas to alert staff to my child's dietary or medical needs.
If your child has a severe or life-threatening allergy or medical condition, please contact the office staff at 651-455-4555 for a supplemental Individual Care Plan to be completed by your Health Care Provider.
I will contact the staff for emergency medical paperwork.
I understand that any special food for my child that is not usually supplied by the school will be provided by my family for school use.
Dodge Nature Preschool tries to provide many healthy options for snacks, including gluten-free, nut-free, dairy-free options, etc.
I will provide special food, if needed.
Medical Insurance*
ALL FIELDS REQUIRED
Carrier Policy # Policy Holder Name
Child's Dentist*
If your child has not yet seen a dentist, please include your dentist's name. We almost never need this information, but are required to collect it.
ALL FIELDS REQUIRED
Dentist or Group Name
Dentist Phone*
Dentist Address*
City State

Medication Release
Families should apply sunscreen and insect repellant before bringing children into Dodge Nature Preschool (when necessary in the spring, summer and fall seasons).
I give permission for the staff of Dodge Nature Preschool to reapply additional sunscreen and insect repellant to my child, as needed.*
- Agree (Sunscreen/Bug Spray)
- Do Not Agree (Sunscreen/Bug Spray)
Please Explain:
I understand that Dodge Nature Preschool must have a prescription and written instructions from a doctor to administer prescription medication or written parental consent for over-the-counter medications.*
- Agree
Information/ Publication Release
I give my permission for my child's name and family contact information (email, phone, address) to be listed in a school directory distributed to his/her class.*
*Directories are only provided during the school year.
- Yes, Include all directory information
- No, Remove us from classroom directory
- Limited Directory Permissions (specify below)
Specify
At Dodge Nature Preschool, we use photographs of children to share with families about our day, to illustrate information in our educational publications, and to share the wonder of Dodge Nature Preschool with the public.*
We do not use children's names when we share photos with the public.
- I give permission for my child's image to be used for these educational or promotional purposes.
- I do NOT want my child's image to be used in/on: (please specify below)
Specify
Field Trip Permission*
I understand that my child will regularly participate in walking field trips on the grounds and to the buildings of Dodge Nature Center.
- Agree (Field Trip)

Permission & Signature*
I give permission to Dodge Nature Preschool to make whatever emergency (first aid, disaster evacuation, etc.) measures are judged necessary for the care and protection of my child while under the supervision of the Preschool.

In case of a medical/dental emergency, I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resource (police or emergency medical respondent) deems it necessary.

It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child's physician and/or other adult acting on the parent's behalf.
Please Enter Your Full Name*
Date*
Month
Day
Year

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Dodge Nature Center Main Office

365 Marie Ave W
West St. Paul, MN 55118
651-455-4531 [email protected]

Monday - Friday
8:00 a.m. - 4:00 p.m.

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