This child may be released to the person(s) signing this agreement or to the following: Your emergency contact should be listed as the person(s) your child may be released.
Persons to contact in case of emergency when parent or guardian cannot be reached:
Emergency Medical Authorization
Should child listed above suffer an injury or illness while in the care of St. Stephen's Summer Saints Program and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibilty for payment for services.
Parental Agreements with St. Stephen's Summer Saints Program
The St.Stephen's Summer Saints Program agrees to provide child care for:
Before any medication is dispensed to my child, I will provide a written authorization, which includes: date; name of child; name of medication; prescription number; if any; dosages; date and time of day medication is to be given. Medicine will be in the original container with my child's name marked on it.
My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by parent (s), or facility personnel.
I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans and immunization records, etc.
The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.
St. Stephen's Summer Saints Program agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.
I authorize the child care facility to obtain emergency medical care for my child when I am not available.
I have received a copy and agree to abide by the policies and procedures for St. Stephen's Summer Saints Program.
I understand that the facility will advise me of my child’s progress and issues relating to my child’s care as well as any individual practices concerning my child’s special needs. I also understand that my participation is encouraged in facility activities.
Terms of Acceptance and Signature
I, the [applicant, requestor,ect.] for this enrollment form, warrant the truthfulness of the information provided in this form.