INFORMATION & HISTORY FORM 2022-2023

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INFORMATION & HISTORY FORM 2022-2023
Please be sure to keep this information up-to-date as the year progresses.
Please let us know when phone numbers, addresses, etc. are changed.

Child's Name

Gender

Date of Birth

Child’s Hebrew Name [if any]

Address

City

Zip

Home phone #

Parent/Guardian Name

Email Address

Cell Phone #

Work Phone #

Home Phone #

Occupation

Hobbies

Parent/Guardian Name

Email Address

Cell Phone #

Work Phone #

Home Phone #

Occupation

Hobbies

Name of Emergency contact:

Relationship

Phone #

Pediatrician Name

Phone #

Dentist Name

Phone #

Permission

My child, named above, has permission to attend all supervised field trips and activities of Keshet Preschool from September 2022 – June 2023. I/We understand that reasonable vigilance in the care and supervision of the children will be exercised. Beyond this I/We will not hold the school or those supervising the trip responsible.

Signature of Parent or Guardian

Date of Initial

I authorize the use of photographs of my child for Keshet advertising. No names will ever be used without additional parent permission.

Signature of Parent or Guardian

Date of Initial

I authorize the use of my child's photograph for in-house purposes only, including newsletters, daily emails, and Keshet's private Facebook page.

Signature of Parent or Guardian

Date of Initial

Transportation

These are the people that you are allowing to pick up your child. Otherwise, we will need written permission to dismiss your child to anyone not noted on this list

Name

Alerts

Things Keshet should know about my child

Allergies and treatment:

Medications:

Accidents, illnesses or traumas:

Developmental Information

Please explain any concerns that you might have about your child’s development:

Social:

Emotional:

Physical:

Techniques for calming your child when upset:

Special interests your child has:

Other information, about your child, that you would like our staff to be sensitive to:

Please be sure to alert our staff if any issues or concerns develop throughout the year. Sometimes changes at home will affect a child’s behavior in school. This information will help us to help your child through any difficulties.
We are committed to a close partnership between home and school.

Sat, June 3 2023 14 Sivan 5783