Please: Read the following and Initial each line individually,
and sign/date at the bottom.
___________I hereby give my child permission to ride on Xilin Academy Day Care Center vehicles/chartered vehicles to and from pre-arranged field trip locations.
___________I hereby give my child permission to go on spontaneous walks around Xilin Academy Day Care Center and the surrounding facilities and adjacent sidewalks.
___________I hereby give consent to utilize my child for the purpose of educational research, and understand that I will be notified properly and adjacent sidewalks.
___________I hereby give consent to have my child’s picture taken and used for publicity purpose (i.e. newspapers, articles).
___________I hereby give permission to Xilin Academy Day Care Center personnel to apply health care treatment including emergency first aid to my child in case it is needed.
__________I may occasionally telephone authorize release of my child to persons other than those listed on my child’s enrolment form.
___Yes___No Confirmation of all telephone-authorized release shall be made by contacting me at _________________________.
___________________________
Name of Child
___________________________
Signature of Parent of Guardian
___________________________
Date