Consent Form

Child Name *

First

Last

Please list below, people who have your permission to pick up your child: No one under the age of 18 may pick up a child – no exceptions. This is a DSHS regulation. If anyone, other than a guardian or the persons indicated below, is picking up a child on any particular day, written notice is required. *

First

Last

Phone

Name

First

Last

Phone

If you need more space to add people who have permission to pick up your child. please use the space below. Provide first and last names and phone numbers for each individual.

Field Trips- I give my permission for my child to go on neighborhood walks, visit neighborhood parks, playgrounds, Mt. Baker beach, and ride public transportation. *

I hereby grant to Central Branch Preschool and to its employees, and board members the right to photograph/video myself and my child, and use the photo and or other digital reproduction of me/him/her or other reproduction of me/his/her physical likeness for publication processes, whether electronic, print, or digital.

Sunscreen- I authorize Central Branch staff to apply sunscreen to my child as needed.

Medical Consent- I authorize consent to medical, surgical, and hospital care, treatment, and procedures to be performed for my child by a licensed physician or hospital, when deemed immediately necessary or advisable by the physician to safeguard my child’s health and when I cannot be contacted. I authorize consent for transport of my child to receive such treatment. I waive my right of informed consent to such treatment. *

I give my permission to share our contact information with Central Branch Families.

Date / Time *

Date

Time

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