Preschool Permission and Release Form

Child's Name*

First Last

Nickname (if any)

Child's Birthdate*

Parent/ Guardian Name(s)*

Tell us a little bit about your child's strengths and weaknesses.

Please share some brief information regarding your child’s needs, interests, and abilities. If you believe your child may have educational or health needs which will require additional planning or preparation on the part of the school, please include those below.
If you would like your child to be placed with a sibling or friend, please include that below.

Please indicate any placement preferences for your child.

We cannot guarantee placement with a specific teacher, friend or sibling, but we will try.

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)
developmental or learning needs with an IFSP or IEP.
food intolerances or special dietary needs.

If available, please provide a copy of your child’s IFSP/IEP/ICCP.

Max. file size: 100 MB.

Please describe allergies, needs or dietary restrictions; care required or appropriate response for any conditions specified above:

Permission to Alert Staff*

By clicking the box above, 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.*

Agree

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.

Agree

Our school values diversity in the broadest sense, taking into account the differences in gender, culture, religion and heritage. Are there any special considerations regarding your child for which we should be aware and/or ways in which your family could enhance and/or support the school’s commitment to diversity?

Can English be used for all preschool communications?

Yes
No

Please indicate if a language other than English is spoken at home.

In order to help us track our demographic information, please provide the following information. Student’s racial/ethnic background:

African American
Latino / Hispanic
American Indian
Pacific Islander
Asian
Middle Eastern
Caucasian
Other (specify below)
Multiracial (specify below)

Specify:

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
Do Not Agree

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
No
Limited (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, including classrooms in the Farm Education Building (1701 Charlton St.).

Agree

Permission & Signature*

I have read carefully and understand the information on this form. I have indicated my consent and authorization where applicable.

Please Enter Your Full Name*

Email

Please enter your email address here for email confirmation of this form.

About Camps

Scholarships

Offices Closed – Trails Open

Monday, May 29th

Egret Society Planned Giving Luncheon

Sunday, June 4th

Green Seniors: Turtle Time

Monday, June 5th

Preschool Permission and Release Form

Preschool Summer Information & Permission Form

Medication Release

Information/ Publication Release

About Camps

Scholarships

Offices Closed – Trails Open

Monday, May 29th

Egret Society Planned Giving Luncheon

Sunday, June 4th

Green Seniors: Turtle Time

Monday, June 5th

Preschool Permission and Release Form

Preschool Summer Information & Permission Form

Medication Release

Information/ Publication Release

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