EMERGENCY CONTACT INFORMATION LIST ALL OTHER ADULTS YOU AUTHORIZE CONNECT STAFF TO RELEASE YOUR CHILD TO:
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1 AFTER SCHOOL PROGRAM Fall Spring CHILD PERSONAL DATA SHEET Child s DOB Home Address City State Zip Gender School Enrolled in: : Employer Employer Work APP Requested Work APP Requested EMERGENCY CONTACT INFORMATION of person to call if parents cannot be reached Relationship Address City State Zip Do you authorize Connect staff to release your child to this person? LIST ALL OTHER ADULTS YOU AUTHORIZE CONNECT STAFF TO RELEASE YOUR CHILD TO: Relationship Relationship Relationship Page 1
2 SUNRISE CONNECTions & CONNECT AFC MEDICAL INFORMATION Child s Physician Address City State Preferred Emergency Treatment Facility do hereby give my consent to the Director of CONNECT, (Child s ) or her duly representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parents cannot be reached. Consent is also given for the Director or her duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached. I hereby give / do not give the Director of CONNECT or her appointed representative permission to give acetaminophen. (Child s ) I understand I will be notified that the medication has been adminstered. IMMUNIZATIONS Please Provide a copy of your Child s Immunization Record. Verified by Health Department Record Physician s Record Other DISEASE HISTORY Measles Mumps German Measles Chicken Pox Wooping Cough Contracted Tuberculous: Yes / No Defective Heart: Yes / No Frequent Throat Infections: Yes / No Frequent Ear Infections: Yes / No SUNSCREEN PERMISSION FORMS do hereby give / do not give my consent to (Child s ) the Director of CONNECT or any Staff Member, to apply any type or brand of sunscreen available to said child in the event parent provided sunscreen is unavailable. Page 2
3 SUNRISE CONNECTions & CONNECT AFC CHILD S DEVELOPMENTAL NEEDS Physical or emotional needs the child might have: Child s Special Food Needs: Diabetic Diet Allergies Other Child s Additional Needs: Medications Allergies Temper Tantrums Diabetes Biting Frequent Colds Sun Sensitivity Seizures Fainting Spells Bathroom Modifications Other Requires Help in: Dressing Undressing Toileting Eating Washing Hands Favorites: Games Toys Foods Siblings: Age Age Age Age Type of Childcare Used Before: Other Useful Information: the parent/guardian of this child, understand that I may ask for a conference with the caregiver(s) as needed. (ature) () Additional Comments: Page 3
4 INTERNAL PHOTO RELEASE PERMISSION do hereby give / do not give my consent to (Child s ) the Director of CONNECT or any Staff Member, to use photographs taken during class time, field trips, special events or celebrations to post INTERNALLY in classrooms, hallways, for teacher education, and as a historical record. EXTERNAL PHOTO RELEASE PERMISSION do hereby give / do not give my consent to (Child s ) the Director of CONNECT or any Staff Member, to use photographs of my child for publicity purposes. This includes, but is not limited to: brochures, the CONNECT AFC website, CONNECT AFC Facebook, and any other type of print or digital media used as promotional materials. I understand that when photographs are used for publicity purposes, children are never identified by name and that all photos used for publicity will be available for me, the child s parent/guardian, to review upon request. In addition, I understand that I reserve the right to request that any photograph or video not be used for publicity. Page 4
5 SPRING AFTER SCHOOL PROGRAM COMMITMENT FORM am certifying that my child will be enrolled at (Child s ) CONNECT AFC s SPRING 2018 Program which runs from January 3rd - May 25th, 2018 and that I am responsible for payment for all weeks. My commitment guarantees my child a spot for all days CONNECT AFC is open. OR am certifying that my child will be DAY RATE (Child s ) STUDENT IN CONNECT AFC s SPRING 2018 Program for the following: (write in the days - example every Tuesday - the dates - example week of - or write in drop in student only) I understand there is no enrollment guarantee for DROP-IN STUDENTS and that all spots are first come first serve pending DHS capacity and pre-payment in full. Page 5
6 print Child(REN) (S) Financial Commitment BANK ACCOUNT and/or debit card INFORMATION I have read and fully understand my commitment to CONNECT AFC, LLC as outlined in the Registration Packet and Parent Handbook. I understand my commitment is for term I indicated on my Registration Forms. I understand that I am giving my financial information to be used to pay my account fees in full each FRIDAY prior to the week services will be provided or used daily to pay for drop in TUITION or special cost Fees associated with the program. signature date name as it appears on Account or card billing address zip code Type of Account: Checking Savings Other bank routing # bank account # Type of CARD: visa mastercard discover CARD # EXPIRATION cvv # Page 6
7 Transportation and/or Field Trip Permission form for (print Child s ) Guardian (CROSS OUT WORDS THAT DO NOT APPLY) do hereby give my consent for my child to be transported by Connect AFC to designated activities and/or to attend all field trips conducted as a part of the CONNECT AFC Program. Emergency Contact Information Contact Contact Phone # Secondary Contact Secondary Contact Phone # do hereby give my consent to the Director of (Child s ) CONNECT AFC, or her duly representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency while on a field trip when the parents cannot be reached. Consent is also given for the Director or her duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached while said child is on a field trip.
8 KID SHUTTLE ACTIVITY Transportation Permission form for (print Child s ) Guardian (CROSS OUT WORDS THAT DO NOT APPLY) do hereby give my consent for my child to be transported by Connect AFC to designated activities and/or to attend all field trips conducted as a part of the CONNECT AFC Program. Activity List ACTIVITY location day OF WEEK & time do hereby give my consent to the Director of (Child s ) CONNECT AFC, or her duly representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency while on a field trip when the parents cannot be reached. Consent is also given for the Director or her duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached while said child is on a field trip.
9 Care Plan for: (print Child s ) (to be completed by doctor or parent/legal guardian) Medication/procedure: Dosage/time to administer: reason: Possible side effects: any other information child care provider might need to know: Is it necessary for student to receive during normal child care provided hours? YES NO I medically delegate the task of this procedure and/or the administration of this medication to any person duly trained and validated by RN to be competent. signature Address I request that you give medication to my child during the time enrolled at Connect AFC Program(s) in accordance with the policy stated in the Parent Handbook. Your are authorized to delegate this authority to another person if so desired. I understand in the absence of the director, a designated member of the staff instructed in the procedures for medication administration, may give this medication. I will not hold CONNECT AFC or it s staff responsible for any undesired reaction, which may occur from the medication. Medication Policy Guidelines: It is the policy of the Board that no drug medicinal preparation will be administered to a student by any connect afc personnel unless a current valid doctor s prescription and instructions as well as a written request from the child s parent/guardian is on file. Prescription medication must be in a current prescription bottle with the pharmacy label. Parent signature Page 9
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