Form:Student Information

Student Information

  • Emergency authorization: I understand that every effort will be made to contact my/our family or emergency back-up people if there is an emergency requiring medical attention for this student. If I cannot be reached, I authorize the Winn Brook Child Care Program (WBCC) to have this student transported to the Mt. Auburn Hospital and to secure for this student necessary medical treatment. I also authorize the WBCC staff trained in first aid to attend to this student when appropriate.
  • To ensure thorough care for my/our student, I/we give permission to WBCC staff members to communicate and participate with my/our student’s classroom teachers, principal, guidance counselor, school nurse, etc., as needed. I understand that the school will be informed of this consent. (Please note: the WBCC staff uses a separate written release form for private physicians, therapists, psychologists, etc.)
  • I/we give permission for this student to go on walks with the program, chaperoned by the WBCC staff. I/we understand that these walks are in the general neighborhood of the Winn Brook School (e.g. Belmont Center, Belmont Public Library). I understand that all field trips using school bus or other transportation will require a separate release form.

Family Information


Emergency Contact Release

  • In the event of an emergency or my inability to pick up my child from WBCC, I hereby authorize the WBCC staff to release my child to the following people. I understand that these authorized persons may be asked to provide identification to the WBCC staff. PLEASE NOTE: WBCC requires at least one emergency back-up name and number. Please see the WBCC Director if you cannot provide this information.
  • Please notify WBCC of any person(s) who may NOT pick up your child per 209A (restraining order) Commonwealth of Massachusetts.


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