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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
N/A or Unknown
Male
Female
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.
Please Select One
YES
NO
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.
Please Select One
YES
NO
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
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.
Thu, November 30 2023 17 Kislev 5784