Child's Name *
Child's Name
Date of Birth
Date of Birth
You will pick your child up at:
Allergies / Restrictions
Is your child allergic to any medications, foods, environmental, or other substances? *
Is your child restricted from eating certain foods or participating in any activities? *
BEHAVIORAL
Does child have any sensory, physical and/or behavioral difficulties that you believe would be helpful for the supervising staff to know about? *
Emergency Contacts
Please list phone numbers in the order we should call.
Authorization for sign-out & pick-up
Medications
*Please Note: The Lock-In Staff will not be administering any medications to children. This is solely the responsibility of parents. *
INFORMED CONSENT & AUTHORIZATION for EMERGENCY TREATMENT and TRANSPORTATIONSection
1. I understand that I will be notified if my child, listed on this form, becomes injured and/or ill while attending Children’s Lock-In.
2. I agree that upon notification of my child’s injury and/or illness, I will have her/him picked up immediately.
3. In case of an emergency or when I cannot be reached, I hereby give authorization to the Children’s Lock-In staff to contact other emergency contact people listed on this form. If no one listed on this form can be reached, then I hereby give authorization to the Children’s Lock-In Staff and the treating physician to obtain or provide whatever medical treatment and/or transportation deemed necessary for the immediate welfare of my child, listed above.
Condition of enrollment:
I have read, understand and agree to the terms and conditions listed on this Emergency Contact Form and I understand it is my responsibility to provide accident and health insurance coverage for my child and I will be financially responsible for all charges and fees for emergency medical treatment and/or transportation, regardless of whether my medical insurance covers such charges and fees.
Date Signed *
Date Signed