INFORMATION CHANGE FORM

Please indicate any CHANGES you'd like to make to the information in the spaces below. Enter your child's name on the form, and then only fill in the spaces that have changed from your original enrollment or re-enrollment application.

PARENTS' INFORMATION

List the parent or guardian who will be the main contact for the school on the first set of parent spaces below.

AUTHORIZATIONS

Yes   No

My child's name and class days along with my email address may be included in the school directory issued to all enrolled families. (If "No", I understand no mention of my child will be included on the directory.)

I acknowledge that my child's photo may be taken and used in school newsletters, brochures, flyers, on the school website, and on the school's online social media accounts for marketing purposes. (All photographs taken by staff and volunteers on school grounds are the sole property of Pikake School.)

CONSENT TO RELEASE

Other than you (or the co-parent listed above,) who has YOUR PERMISSION to pick up your child from school? (Picture ID will be required. Leave blank if no one else has permission to pick up your child.)

In the event of a MEDICAL or OTHER EMERGENCY, if neither parent can be reached, the following people have your permission to pick up your child. (If the people are the same as the ones listed above, indicate "Same As Above" in the first box below.)

Information about anyone who MAY NOT pick up your child under any circumstances, if applicable. (A copy of supporting court documentation must be provided for your child’s file.)

SIGNATURE

I acknowledge these changes reflect my current information.

1250 112th Ave NE, Bellevue, WA 98004

t: 425-453-1881

© 2017 PIKAKE SCHOOL