Student Information / Release FormThis form is to be completed by Parent/Guardian We must have a signature on file, so you must print this form, fill it out and sign it, and return it to the Faith Formation staff. It can be delivered to the office or faxed.
There is a "link" to View Printable Page on the right side just above these instructions.
ST. FRANCES CABRINI CHURCH - Student Information / Release From
I, ____________________________________ am a parent or legal guardian of the following children:
My child has an Individual Education Plan (IEP) at place in her/her school: ________ YES ________ NO
I would like to speak with program staff to discuss my child's needs: ________ YES ________ NO
Please list information related to special needs, allergies, food restrictions, and activity restrictions for each child:
My child ______ MAY ______ MAY NOT be photographed for use on parish bulletin boards, website and other promotional material,
The following individual(s) is/are NOT allowed to pick up my child: _______________________________________.
I understand that only my child's teacher and the program staff will have access to this information. In the case of a
medical emergency or if a child requires the administration of an Epi-pen, 911 will be called and the child will
be transported to Fairview University Hospital at Riverside. Parents/Guardians will be contacted at the number below.
_________________________________________ ______________ ___________________________________________
Signature of Parent/Guardian Date Phone number to call in case of emergency.
Please return this authorization to:
Faith Formation Staff St. Frances Cabrini Church 1500 Franklin Ave SE Mpls 55414
You may also fax this completed form to 612-339-0734