Child's Pre-Admission Record

Required

St. James School

Pre-Admission Record Form

This section is to be completed by the child's parent or guardian. This form must be kept in the child's file in the school.

Daterequired

Must contain a date in M/D/YYYY format

Child's Date of Birthrequired

Must contain a date in M/D/YYYY format

Child's namerequired

First Name

Middle (optional)

Last Name

Name child is known by:required

Home addressrequired

Cityrequired

Staterequired

Must contain only letters

Zip Coderequired

Must contain only numbers

Mother's Name (or First Guardian)required

First Name

Middle (optional)

Last Name

Mother's Cell Phonerequired

Mother's Email Addressrequired

Mother's Employer

Mother's Employer's Phone:

Mother's Employer's Address

Please include street address, city, state and zip.

Father's Name (or 2nd Guardian)required

First Name

Middle (optional)

Last Name

Father's Cell Phonerequired

Father's Email Addressrequired

Father's Employer

Father's Employer's Phone:

Father's Employer's Address

Please include street address, city, state and zip.

EMERGENCY PROCEDURES:

Instructions regarding how to reach the parent or guardians in case of an emergency:required

Name of first person to contact in an emergency if parent/guardian cannot be reached: (in order):required

Phone number of first personrequired

Address of first personrequired

Please include street address, city, state and zip.

Relationship to child of first personrequired

Name of second person to contact in an emergency if parent/guardian cannot be reached:

Phone number of second person

Address of second person

Please include street address, city, state and zip.

Relationship to child of second person

Name of third person to contact in an emergency if parent/guardian cannot be reached:

Phone number of third person

Address of third person

Please include street address, city, state and zip.

Relationship to child of third person

Name of Child's Doctorrequired

Doctor's Phone:required

Doctor's Addressrequired

Cityrequired

Staterequired

Must contain only letters

Zip Coderequired

Must contain only numbers

Emergency Authorization:

By adding my electronic printed signature below, I give permission for the school to obtain emergency medical treatment, including emergency transportation for my child, if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If a parent/guardian refuses to sign, instructions must be added below stating what procedure the school is to follow in an emergency.)

Namerequired

First Name

Last Name

Signature of parent/guardian:

If you do not sign above to obtain emergency medical treatment, describe instructions stating what procedure the school is to follow in an emergency:0 / 800

PERSONS THE CHILD MAY BE RELEASED TO:

Name of first person the child may be released to:required

Phone of the first person the child may be released to:required

Address of the first person the child may be released to:required

Relationship to the child of the first person the child may be released to:required

Name of the second person the child may be released to:

Phone of the second person the child may be released to:

Address of the second person the child may be released to:

Relationship to the child of the second person the child may be released to:

Name of the third person the child may be released to:

Phone of the third person the child may be released to:

Address of the third person the child may be released to:

Relationship of the third person the child may be released to:

Name of the fourth person the child may be released to:

Phone of the fourth person the child may be released to:

Address of the fourth person the child may be released to:

Relationship to the child of the fourth person the child may be released to:

PERMISSIONS FOR ACTIVITIES:

I give my permission for my child to participate in activities away from the school:required

Yes

I give my permission for my child to participate in transportation provided by the school:required

Yes

I give my permission for my child to participate in swimming/wading activities provided the school:

Yes

I wish to have my contact information published in the school directory. (This section is password protected and not available to the general public).

Yes

Signature of parent/guardian:required

Name of person filling out this formrequired

First Name

Last Name

Relationship to the childrequired