Falls Church Child Information and Emergency Form 2015-2016 Child's InformationName* First Last DOB*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Class* Language* Program* Travel and Activity InformationI give permission for my child to leave CommuniKids Preschool premises under the supervision of staff members for neighborhood walks, walks to the park, and trips to special places.Restrictions on such trips include:*In case of an emergency, I give permission for my child to receive medical treatment.* Yes No In case of such an emergency, please contact:Name:* Phone*Parent/Guardian Initials* Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Acknowledgement of Receipt of Policies and Waiver ReleasePlease carefully review CommuniKids Preschool Operating Policies for the School Year 2015-2016. Please initial below confirming that you have read that document.I have received a copy of CommuniKids Preschool Operating Policies for the School Year 2015-2016, and I have read and understood the policies.Parent Initials* Waiver ReleaseThe undersigned parent or guardian releases CommuniKids Preschool from any and all liability, loss, damage, costs, claims and/or causes of action, including but not limited to all bodily injuries arising out of participation in CommuniKids programs. The undersigned further agrees to indemnify CommuniKids Preschool, its employees, members, agents, representatives, and other organizations affiliated with it and hold it harmless for any liability, loss, damage, costs, claims, judgment or settlement which may be brought or entered against it as a result of participating in its programs. All participants agree that any photography or video taken while participating in a class or special event may be used for promotional purposes for CommuniKids Preschool. All materials are the copyright of their respective owners.Parent Initials* Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
