PERMIT AND AGREEMENT FORM
Choosing YES to the following questions is the equivalent of a signature.  Completing this form will give permission for as long as the child is enrolled in the program
Sign in to Google to save your progress. Learn more
Child's Name (Last, First) *
1. PHOTOGRAPHY/VIDEOTAPING PERMISSION:  The program has permission to photograph and/or videotape my child and myself, and to post or publish those photographs or tapes. Places where they may be published or posted are: Local newspaper, school website, school records, newspapers, brochures or visual presentations about the program, bulletin board displays, social media, etc. Pictures and videotapes may become a part of the child's educational record. I understand that I will not be able to inspect/approve the written material accompanying the photographs or tapes prior to distribution. *
2.  SPECIAL CONDITIONS:  Please list any religious or ethnic holidays/customs that may affect your child's participation in the program.  
3.  I give my permission for the program staff to attend to my child's needs in the event of illness, bathroom accident, or toilet training needs. This permission includes changing my child's clothing or diapers, cleaning my child, or in other ways making my child comfortable after the event. *
4.  I give my permission for preschool staff to transport my child home or to an emergency contact person if they are ill and no other transportation is available. *
5.  RECORDS:  I give my permission for the program to send any educational and health records of my child to the school district. I understand that I have the right to look at these records before they are sent. These records are sent to the school district in order for public school personnel to plan for my child's education. In the event that I move to a new school district within the Murray Head Start service area, I give permission for my child's records to be transferred. *
6.  I give my permission to have the results of health and developmental screenings from medical providers, health department, school district, etc that are required for enrollment/continued enrollment, to be sent to the Head Start Program . *
CHOOSE YES BELOW TO INDICATE YOU UNDERSTAND THE FOLLOWING.  YES ALSO IS THE EQUIVALENT OF YOUR SIGNATURE ON THIS FORM:
1.  The only exceptions to complete confidentiality are situations in which the staff would determine you or your child to be a danger to self or others; if you are physically or sexually abusive with a child, adolescent or adult; or if you are involved in a trial and the court requires staff to testify. Such situations are extremely rare, and these limits to confidentiality can be discussed with the staff at your center.
2.  I commit to having my child in school every day except when he/she is ill or there is a family crisis. I agree to allow staff to make home visits during the school year. I will volunteer to help the program at school, center, or in my home, as I am able. I will attend parent meetings, center activities, and parent education sessions whenever possible. I agree to have a TB skin test and criminal records background check (if required by my child’s school district) before I regularly volunteer, for the children's protection and my own.                   I understand that I can make changes in this consent form at any time.  
3.  I understand current Kentucky law requires all children to be in proper car seat restraints when being transported in a car. You are expected to abide by Kentucky law when dropping off and picking up your child from our centers.
. *
Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Murray Independent School District. Report Abuse
Google Forms