Name of Child. Grade: Teacher:
Name of Child. (“Child”) (Please print the full name of the Child)
Name of Child. Grade: 8th Homeroom: School: Prairie Hills Junior High Laptop Description: Dell 3340
Examples of Name of Child in a sentence
Name of Child Care Center Signature (Parent/Authorized Representative) Date NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to parent/authorized representative.
Early Childhood Pre-K Health Record Supplement* Name of Child: Name of Child Care Facility:Child’s DOB: To Be Completed By The Physician1.
I hereby authorise the Nominated Supervisor or staff to administer one dosage of Panadol to my child (Name of Child) if his / her temperature is 38 Degrees Celsius or higher, only if all other methods have been unsuccessful in reducing the temperature.
I hereby authorise the Nominated Supervisor and/or staff to apply 30+ sunscreen on all unprotected areas of the skin on my child (Name of Child) for outdoor play.Signature: .........................................................................................
Name of Child: ...................................................
More Definitions of Name of Child
Name of Child. DOB: Age: Sex: Child’s health history and current health problems: Any special medical conditions, including chronic health problems: Any special medications and/or restrictions: Are your child’s immunizations up to date? If not, what is needed? Has your child had any of the following common childhood illnesses? Chicken pox yes no Measles yes no Whooping cough yes no German measles yes no Mumps yes no Rubella yes no Scarlet Fever yes no German measles yes no Rheumatic Fever yes no Is your child prone to: Ear infections yes no Headaches yes no Sore throats yes no Stomach upsets yes no Colds yes no Heart disease yes no Diabetes yes no Upper Respiratory Infections yes no Other: Does your child have any speech, hearing, or visual problems? Has your child ever been tested for any of the above? Describe: Has your child ever had any surgeries? Describe: Known medical problems: Last tetanus shot: / / Reaction?: Yes No Child’s Blood Type: Drug Reactions: Contact with Tuberculosis: TB Test (date): result Chest x-ray (date): result Sickle Cell Agreements: Test (date): result Allergies: When my child is ill, I understand and agree that One Step Up will not accept my child for care. This includes: fever, diarrhea, vomiting, bad cough, all cold spymptoms due to COVID-19 and discharge from nose/eyes of any color than clear, and all communicable diseases. My signature below certifies that my child is to my knowledge, in good health, and free of disabilities that would endanger him/her or other children. Also by signing below I agree that this is a legally binding form. Providing false information could be grounds for termination of childcare services, forfeiture of retainer, or both. Father/Guardian’s Signature Date Mother/Guardian’s Signature Date XxXxxx Xxxxxxxx/One Step Up Childcare Date Authorization for Emergency Medical Care If I cannot be reached to make arrangements for emergency medical care for my child at the time of an illness, accident, or injury, I give my permission for: One Step up - Childcare Sick Child Policies
Name of Child. 2nd Child: Child’s Teacher Name/Age: Parent Name(s), Email, and Phone # Please list all known allergies, physical limitations, concerns: Anything else you’d like me to know about your child(ren)? Class Options: Tuesdays 8:15-9:00 Wednesdays 12:30-1:15 Please note: Children participating in class without a parent/guardian must be potty-trained and able to follow-along in a group setting. Participants may bring a towel or yoga mat. Each class requires a minimum of 5 students to begin a 4-week series. The cost of each 4-week series is $40.00 per/student (months with 5 class days will be charged accordingly). Siblings of the first registered student will be $35.00 for the 4-week series (or $45 of a 5-wk series). Missed classes can be made up with prior communication with Kidding Around Yoga with Xxxx. If anyone other than the Parent/Gaurdian or Emergency Contact will be picking up your child, please communicate with Kidding Around Yoga with Xxxx to ensure the safety of your child. Kidding Around Yoga with Xxxx – xxxxx@xxxxxxxxxxxxxxxxx.xxx – 813.484.4673 xxxxx://xxxxxxxxxxxxxxxxx.xxx/xxxx/ - Follow me on Facebook too!
Name of Child. Signature: Date: Print Name: Relationship to Child: EMERGENCY CONTACT PARENTAL CONSENT FORM 55 PA CODE CHAPTERS 3270.124(a)(b), 3270.181 & 182, 3280.124(a)(b), 3280.181 & 182, 3290.124(a)(b), 3290.181 & 182 CHILD’S NAME BIRTH DATE ADDRESS MOTHER’S NAME/LEGAL GUARDIAN HOME TELEPHONE NUMBER E-MAIL ADDRESS MOBILE TELEPHONE NUMBER ADDRESS BUSINESS NAME BUSINESS TELEPHONE NUMBER ADDRESS FATHER’S NAME/LEGAL GUARDIAN HOME TELEPHONE NUMBER
Name of Child. DOB: If School Age, What grade & school?
Name of Child. DOB: If School Age, What grade & school? Parent/Guardian Name(s): Contract for Services: Mondays Tuesdays Wednesdays Thursdays Fridays From: To: From: To: From: To: From: To: From: To: 5 days a week: 4 days a week: 3 days a week: Part Time: (1-2 days a week) BB4C Wrap Around: (Less than 4.5 hours) Before School & After School As a parent/guardian of the child, I agree to: ● Comply with the policies and procedures regarding fees and payments. I understand that payments for the next two weeks are due on the Friday AFTER I receive my statement. A $15 late fee will be assessed for payments made after that time. ● Abide by the program’s health policies prohibiting my child from attending the program when sick. ● Pay for any non-attendance days beyond the personal days allocated. ● Pay an After-Closing Fee of $15 for any portion of a quarter hour the child is on the premises past 6:00 pm. This is per child.
Name of Child. Class: Date: Address: Illness: Name of Medicine: Any known side effects? Date Dispensed & Name of Doctor: Length of Treatment: Dosage: Time to be given: Any special Instructions/precautions? Can this be self-administered with adult supervision? YES / NO Name of Parent/Carer: Daytime Telephone No: Relationship to pupil: Address if different form the child: I understand and agree to: My child reporting to the appointed person at the prescribed time in order to receive their medication. Whilst every reasonable effort will be made to remind children to report for their medication, school will not be held responsible should a dose be missed. Medication will be given according to the instructions given by your child’s doctor, from their own clearly labelled medication. We are unable to administer any medication without such a label. Signature of Parent/Carer: Date:
Name of Child. Grade: Birthdate: (Required) CONTACT INFORMATION (For Parent/Guardian) Will be manually added to SI Play registration Parent/Guardian's Name(s): (Required) Address: (Required) Cell Phone Number: (Required) email: (Required) Cell Phone Number: email: The above-named child and the undersigned parent and/or guardian of the above named child, understand and acknowledge that the sports including basketball entails both known and unknown risks, including, but not limited to, physical and emotional injury. Knowing these risks, the undersigned assume full responsibility and voluntarily participate. The undersigned, individually and on behalf of the above-named child, hereby voluntarily and expressly release, indemnify, forever discharge and hold harmless the Coyote Hoops Club (including its coaches, administrators and referees), and the 3D Hoops Institute, and Xxxxxxx Public Schools (the “Released Parties) from any and all liability, claims, demands, causes or rights of action, whether personal to the undersigned, to the above named child, or to a third party which are in any way connected with the above-named child’s participation, including those claims allegedly caused by the sole negligence, recklessness, or gross negligence of the Released Parties. In consideration of the above-named child being permitted to participate, the undersigned further agree to indemnify the Released Parties from any and all claims which are brought by, on behalf of, or through the above-named child, including those claims allegedly caused by the sole negligence, recklessness, or gross negligence of the Released Parties. We understand that we are required and provide our own insurance and fully understand that any of the above Released Parties are not responsible for any insurance claims Signature of Parent/Guardian Date