ROCK PAPERWORK CHECKLIST Thank you for registering for the ROCK Before/After School Program, a ministry of Zionsville United Methodist Church. Please make sure you have each of the following documents completed before turning in your paperwork: Registration Form Parent Notice Immunization Form Bonus Day Form Discipline Policy Medication Form Medical Consent Waiver and Release of Liability I, the undersigned, have received and completely filled out all the requested documents, listed above. Parent/Guardian Signature Date
REALLY OUTRAGEOUS CHRISTIAN KIDS A MINISTRY OF THE ZIONSVILLE UNITED METHODIST CHURCH ROCK is a Christian program serving all families by meeting their physical, emotional and spiritual needs. Before and After school Care 2018-2019 Child s name DOB Grade for School year 2018-2019 M / F T-shirt Size Child s Age: Address City: Zip Home Phone: Mother s Bus/Cell: Father s Parent s Home Phone: (if different) Bus/Cell Phone Mother s Name: Father s Name: Parents Address: (if different) City: Zip School Attending: Parent s Email address: See Back for fee schedule AM ROCK (6:45am-9am) Check days desired PM ROCK (2:30pm 6pm) Monday AM Monday PM Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM Your child s Start Date: Zionsville CSC starts 8/8/18 Children s Learning Prog Starts 8/13/18 Emergency contact: Phone Relation Helpful information: (Medications, allergies, fears, any known health problems, recent major changes, etc.) (Initial) I acknowledge that I will need to provide an updated copy of my child s most recent Immunization Records by my child s first day, you or your doctor may fax over a copy to 317-873-2937. Needed for state records Persons having permission to pick my child up from ROCK: (We do I.D.) Our current church affiliation is with P.O. BOX 547 Zionsville, IN 46077 (317-733-4081) Fax (317 873-2937)
REALLY OUTRAGEOUS CHRISTIAN KIDS A MINISTRY OF THE ZIONSVILLE UNITED METHODIST CHURCH ROCK is a Christian program serving all families by meeting their physical, emotional and spiritual needs. REGISTRATION CONDITIONS AND FEES I desire to register my child (name) going into grade during the 2018-2019 school year for the ROCK Program and hereby accept the agreement as follows: Registration fees are $100 per child. Before School care After School Care # of days Tuition due # of Days Tuition due Registered for Each Installment Registered for Each Installment 1 $40.00 1 $48.00 2 $80.00 2 $96.00 3 $120.00 3 $144.00 4 $144.00 4 $176.00 5 $160.00 5 $190.00 Full time morning and afternoon fees are $330 per month. Your registration fee as well as your August 2018 tuition installment is due at the time of registration and is nonrefundable! I understand that I am making 10 equal tuition installments due on the 1 st of each month, August through May (August paid at registration). Checks are to be made payable to ROCK & put in the Black Payment Box. A late fee of $25.00 will be imposed for any payment received after the 15 th of the month. Media Consent: I understand that Photographs/video may be taken at ROCK that could include my child. I give ZUMC/ROCK permission to use these photographs/videos in publications as well as advertisements. If you have any concerns please contact Kathy Gibson. I also understand that no refund will be made for non-attendance. (See Handbook) In signing, I am stating that I agree with the conditions of registration and can review a copy of the ROCK Handbook online at rockzumc.org/forms.html. ADULT: Signature (Parent or Legal Guardian) Printed Name Date **********************************************OFFICE USE ONLY*********************************************** ACS FILE MAIL BOX SIGN IN SIGN OUT EXCEL P.O. BOX 547 Zionsville, IN 46077 (317-733-4081) Fax (317 873-2937)
PARENT'S NOTICE State Form 49444 (R / 1-09) / BCC 0035 I understand that this day care ministry is not licensed under the laws of Indiana. However, I understand that this day care ministry complies with the State rules concerning sanitation and fire safety for the primary use of the structure in which it is conducted. I understand that it is my responsibility to ensure that the nutritional and health needs of my child are met while my child is at the day care ministry. Signature of Parent or Guardian Name(s) of children enrolled This notice does not absolve a day care ministry from liability for injury to a child while the child is at the day care ministry if the cause of the injury is negligence or intentional wrongdoing on the part of the day care ministry or an employee of the day care ministry. Name of facility Address of facility (number and street, city, state, and ZIP code) County
ROCK BONUS DAYS 2018-2019 Who: All ROCK Participants What: All day ROCK on the days listed below When: October 15-19, 2018 February 18 and 19, 2019 May 29, 2019 (possible snow makeup day) Where: ROCK @ Zionsville United Methodist Church Details: When registering, please pay for the days your child intends to come $50 per day Once you have registered, you are expected to fulfill your financial commitment whether your child is in attendance or not. NO REFUNDS. Hours of operation: We will be open from 6:45am 6pm each of these days. Breakfast and two snacks will be provided. You must provide lunch for your child. Activities: Activities for these days will be similar to our summer program. I am registering for (insert dates interested in from bold dates above, name & grade): Date: Child s Name: Grade: Date: Child s Name: Grade: Date: Child s Name: Grade: In signing I am stating that I agree with the above registration conditions as well as the conditions stated on the School year Registration form and in the ROCK handbook. Parent s signature Date
ROCK DISCIPLINE POLICY The philosophy of the ROCK program is to ensure that each participant is provided a safe, Christian, education environment where children have structured freedom to explore, experience, and discover various aspects of physical and spiritual growth with guidance from educationally qualified, caring professionals. The purpose of the ROCK Discipline Policy is to ensure that each participant conducts themselves in a manner that will promote and maintain an atmosphere that nurtures feelings of respect, safety, belonging, and being loved. Obtaining and maintaining desirable behavior from our participants is a shared responsibility between child, parent, and ROCK staff. The following is expected of each participant whether they are in the ROCK building, on the ROCK bus or on an offsite field trip. Each participant is expected to: Show respect for staff and other participants Show respect for the Church and its facilities. Exhibit self control and an attitude of cooperation. Follow the rules and have an attitude of obedience. Be encouraging towards others. Each participant is expected NOT to: Use inappropriate language, disrespectful language, or put downs." Bully other children in any way. The ROCK staff will maintain communication with the parents of children who are struggling with any behavioral issues. Participants who choose to continuously cause disruption, disobey, be disrespectful or cause harm to others will be disciplined accordingly, as follows:
1st offense -The child will be taken aside for discussion 2nd offense -Timeout 3rd offense - A letter.will be sent home requesting a conference with the child's parents in order to create a plan to halt this behavior; 4th offense -The child's parent will be called to pick their child up from ROCK immediately. 5th offense - The child will be dismissed from the ROCK program until behavior is corrected. The discussion to allow a child to return is at the discretion of the Director and Assistant Director. This policy may be altered at the discretion of the Director and the Assistant Director. In signing, I am stating that I have received and read a copy of the Rock Discipline Policy. I am also stating that I understand the policy. Parent/Guardian Signature Date ROCK Participant Signature Date
ROCK MEDICATION PERMISSION Student s Name Age A few children experience an allergic reaction to the sting of bees, wasps, hornets, and/or food. Since allergic reactions can be serious at times and require prompt treatment, ow medical consultant has recommended that the staff administer oral Diphenhydramine HCL ( Benadryl ) to children who have been stung or are exhibiting a reaction to food, dye, or juice. YES, the ROCK Program is hereby given permission to administer the medication Diphenhydramine HCL ( Benadryl ) by mouth to my child, named above, according to the dosage outlined below, in the event that my child is stung by a bee or wasp at camp or exhibits a reaction to food. NO, I DO NOT wish for my child to be given oral Diphenhydramine HCL ( Benadryl ) in case of a bee or wasp sting, or a reaction to food. Please provide a reason for this decision below. REASON: PARENTS MUST FILL IN DOSAGE AMOUNT OR WE CANNOT ADMINISTER THE MEDICATION. DOSAGE FOR CHILDREN 6-12 YEARS OF AGE (Please check one): 1 teaspoonful (12.5mg) 2 teaspoonfuls (25 mg) Other DOSAGE FOR CHILDREN UNDER 6 YEARS OF AGE: 1/2 tsp per 10 pounds (Do not exceed 2 tsp) Dosage Amount YES, my child has had a severe life-threatening reaction to a bee or wasp sting. Please explain the type and symptoms of this reaction and what needs to be done. Parent/Guardian Signature Emergency Phone Number(s)
ROCK MEDICAL CONSENT In the event my child becomes ill or sustains an injury while attending the ROCK Program, a ministry of the United Methodist Church, Indiana, I the undersigned give permission to those in charge to administer first aid. I also consent to an x-ray examination, anesthetic, medical (or dental) or surgical diagnosis and treatment and hospital care, and the administration of drugs or medicine to be rendered to my child under the general or specialized supervision and upon the advice of the duty licensed physician and/or surgeon. I understand that this consent will apply to all emergency situations present and future, and that a copy of this form is valid as the original. This consent is to. remain in effect until written revocation is made. Parent/Guardian Signature Address Date Phone Number Please describe any health issues: Please list any medication your child is taking on a regular basis: (Name of medication, dose, and prescribing physician) Name of Primary Care Physician Phone Number of PCP Hospital of Choice
WAIVER, RELEASE OF LIABILITY, AND CONSENT TO MEDICAL ATTENTION ZIONSVILLE UNITED METHODIST CHURCH 9644 Whitestown Rd., Zionsville, IN 46077 317-873-2623 Fax 317-873-2937 LAST NAME: FIRST NAME ADDRESS CITY STATE ZIP CODE HOME PHONE: EMERGENCY PHONE EMAIL: EVENT: Date: August 8, 2018-May 24, 2019 Destination: Transportation to ZWest, Eagle, PVE, Union, Boone Meadow and Stonegate Schools In exchange for my being allowed to participate in events sponsored by Zionsville United Methodist Church (herein referred to as ZUMC ), I and, if I am not yet 18 years old, my parent or legal guardian (individually and collectively referred to below in the first person singular) agree to be bound by each of the following: 1. Obligation to Inspect Facilities and Equipment. I agree that prior to participating in the event, I will inspect the facilities and equipment to be used. If I believe anything is unsafe, I will immediately advise the supervisor of the event and ZUMC of such unsafe condition(s) and refuse to participate in the event. 2. Identification of Risks. I understand the participation in the event may involve risk of serious injury, including permanent disability and death, and other losses, both to persons and property. I understand that these injuries and losses might result from the actions, inactions, negligence, or conduct of others, the rules of the event, or the condition of the premises or of any equipment used. 3. Assumption of Risk. I assume all risks, known and unknown, in any way connected with my participation in the event. I accept personal responsibility for any liability, injury, loss or damage in any way connected with my participation in the event. 4. Waiver and Release. I waive, release, and hold harmless ZUMC and its directors, officers, sponsors, employees, volunteers, agents, successors, and assigns from all claims for any liability, injury, loss or damage in any way connected with my participation in the event, whether or not caused in whole or part by the negligence or other misconduct of ZUMC or any of the persons mentioned above. I intend for this waiver and release also to apply to any relatives, personal representatives, heirs, beneficiaries, next of kin or assigns who might pursue any legal action or claim for such liability, injury, loss or damage. (over)
Furthermore, in consideration of my child's participation in the event set forth above, I hereby AGREE TO INDEMNIFY AND HOLD HARMLESS ZUMC from any and all claims, demands, rights of actions or liabilities of whatsoever nature that any person had, now has, may have or might in the future have against ZUMC, including but not limited to, any and all claims, demands, rights of actions or liabilities based upon any NEGLIGENCE on the part of ZUMC based upon, arising out of, or in any manner connected with my child's participation in the event identified above. 5. Consent to Medical Treatment. I agree that ZUMC may provide to me, through medical personnel of its choice, customary medical or training assistance, transportation, and emergency medical services. This consent does not impose a duty upon ZUMC to provide such assistance, transportation, or services. 6. Media consent. I understand that pictures of the event which may include my child/children will be available for use in church publications. I HAVE READ THIS WAIVER, RELEASE, AND CONSENT. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I AM SIGNING THIS WAIVER, RELEASE, AND CONSENT VOLUNTARILY. ADULT: Signature (Parent or Legal Guardian) Printed Name Date MEDICAL INFORMATION Medical Insurance Provider: Phone Policy Number : Medical Pre-Certification Procedure (if applicable): Special Medical Information Concerning Patient: (allergies, medications, conditions, etc.) Adopted 4-27-04 ZUMC Church Council