Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:

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1 Adventure Club Before and After School Care Enrollment Packet Before and After School Care Mission: Our before and after school care is designed to provide children with a safe, loving and exciting environment where they can grow in spirit, sour, body and relationships. Morning Care Afternoon Care Both Morning and Afternoon Care Drop in Care

2 Adventure Club Schedule and Tuition Child s Full Name: Last First Middle Gender: Male Female Nickname: Birth Date: Current Age: month/day/year Child s Address: City State Zip Home Phone: PARENT INFORMATION FATHER/GUARDIAN MOTHER/GUARDIAN Name: Name: Address (if different): Address (if different): Home Phone (if different): Place of Employment: Home Phone (if different): Work Phone: Place of Employment: Cell Phone: Work Phone: Cell Phone: With whom does the child live? Both Parents Mother Father Guardian Parents Marital Status: Married Separated Divorced Widowed Single In the case of divorce, who has legal custody of the child*? (*Please note: The school office needs to be notified as to any restrictions regarding who may take the student from the school premises.) Custody/Visiting Arrangements: Restrictions: Visiting rights denied to: (Copy of restraining order must be attached) Is there a full-time sitter? Yes No If yes, NAME and PHONE: 2

3 CHILD S FULL NAME EMERGENCY CONTACTS Other persons responsible for child and permitted to remove child in case of emergency or injury, if parents cannot be reached: Name Address Phone Relationship OUT-OF-STATE EMERGENCY CONTACT Name Address Phone Relationship 1. This contact is needed in the case of a local emergency where local phone lines are down or lines are too busy to get through. NOTE: Parent/guardian must give written notification in the event someone other than persons listed above will pick up the child from school. Please list any other children living in the home: Name, Age, School BEHAVIOR Methods parents find most effective in dealing with good behavior: Methods parents find most effective in dealing with misbehavior: HEALTH INFORMATION Please indicate below if child has or has had any of the following illnesses or chronic diseases: Illness Date/s Illness Date/s Illness Date/s Blood Disease Chicken Pox Chronic Diseases Contacts/Glasses Convulsions Diabetes Ear Infections Emotional Epilepsy Hearing Loss Heart Disease Kidney Disease Measles Mumps Nosebleeds Rheumatic Fever Scarlet Fever Whooping Cough 3

4 CHILD S FULL NAME Please indicate any additional illnesses or medical issues below if child has or has had: ADD/ADHD, anemia, asthma, autism or forms of autism, fainting spells, frequent sprains or dislocations, heart disease, operations, hospitalizations, strep throat, serious injury or concussions, urinary tract infections, or any other condition that affects your child physically or emotionally: Condition Description Date/s Method of Treatment Does the child have any other physical, behavioral, or social difficulties that should be given special consideration? Yes No If yes, please list and describe: ALLERGIES: It is important that we are aware of any allergies that your child has. Please indicate below: Food: Expected Symptoms: Drug: Expected Symptoms: Method of Treatment or Comments: MEDICATION POLICIES: 1. Prescription Medication can only be administered if the parent or guardian completes the medication request form giving us clear directions. All prescribed medication must be in the original container with physician's directions attached. We will only administer prescription drugs that immediately follow the prescription date. 2. Over-the-counter Medications may only be administered if the parent or guardian completes the Medication Authorization Form giving us clear directions. All medication must be in the original container and we will only administer the dosage listed on the label. 3. Any Medication Left at the Center that is past the expiration date and not picked up by the parent/guardian will be disposed of appropriately. Current medications used by child: HEALTH INFORMATION RECORDS Doctor: Date of last physical examination: Phone: Address: Dentist: Date of last dental examination: Phone: Address: MEDICAL INSURANCE INFORMATION Primary Medical Insurance Group Subscriber ID# Secondary/Supplemental Insurance Group Subscriber ID# I have read the policies and verify all information above. Parent/Legal Guardian Signature: Date: 4

5 MEDICAL/SURGICAL CONSENT and FIELD TRIP PERMISSION for: Student s Full Name: Birth Date: Boy Girl I (We), the undersigned parent(s)/legal guardian(s) of the above named child, do hereby authorize transportation to and from and participation in school-sponsored field trips and the authorities of Christian Faith School to permit its designated representative to give consent to a physician and/or hospital for emergency medical and/or surgical treatment when necessary to our son/daughter, for sustained injuries or sickness requiring emergency treatment during school hours; or, after school hours while partaking in schoolsponsored activities, such as educational, social, and athletic events, provided such event or events have an authorized representative of the school present. It is understood that the school or its representative does not assume any financial responsibility for any expenses that might be incurred for said emergency treatment. It is further understood that the school authorities will notify us as soon as possible following the emergency, but in no way is treatment to be delayed until we have been notified. I (We) give permission to Christian Faith School to publish photographs and or video of my (our) child whether in print, on the web, or any other form of media that exists now or developed in the future for the purpose of promoting Christian Faith School. Accept Decline Initial Initial HOSPITAL ADMISSION AND/OR PHYSICIAN S CARE I hereby consent to all medical and surgical treatment by the attending physician and to the administration and performance of all examinations, administering of medicine, treatments, anesthetics, operations, x-rays, blood tests, transfusions, suturing or other procedures, which may be deemed necessary for my child during the stay at this hospital. Doctor: Phone: ( ) Hospital Choice: Phone: ( ) FINANCIAL AGREEMENT I hereby agree to accept responsibility for any financial indebtedness incurred during the hospitalization. I agree to pay for all necessary services at the current rate and in case of collection, pay a reasonable attorney fee and collection expense. I have read the above medical/surgical consent information and understand and agree to its content. Parent/Legal Guardian Signature: Date: Nondiscriminatory Policy: Christian Faith School admits students of any sex, race, color, national, or ethnic origin to all rights, privileges, and activities generally accorded to students of the school and administration of its educational policies, admissions policies, scholarships, or athletic and other school administered. 5