Health Statement. I acknowledge my Child is in excellent health and physical condition. I have disclosed any medical, physical, or mental health condition to Wanna Play Playcare in my Child’s Enrollment Form.
Health Statement. My child is in good health, with activity restrictions noted on the emergency card. Immunizations are up to date and on file with the school and/or appropriate waiver is on file with the school. Parent/Guardian Signature Date _ Field Trip Permission (Summer Kids Club only) Notification will be provided to parents prior to any off site field trip. I give my permission for my child to be transported by the South Lyon Community Schools transportation personnel and for my child to take walking field trips with Kids Clubstaff. Parent/Guardian Signature_ Date _ PARENT NOTIFICATION OF THE LICENSING NOTEBOOK Child Care Organizations Act, 1973 Public Act 116 Michigan Department of Human Services All child care centers must maintain a licensing notebook which includes all licensing inspection reports, special investigation reports and all related corrective action plans (CAP). The notebook must include all reports issued and CAPs developed on and after May 27, 2010 until the license is closed. • This center maintains a licensing notebook of all licensing inspection reports, special investigation reports, and all related corrective action plans. • The notebook will be available to parents for review during regular business hours • Licensing inspection and special investigation reports from at least the past two years are available on the Bureau of Children and Adult Licensing website at www. xxx.xxxxxxxx.xxx/xxxxxxxxxxx. I have read the above statement issued by South Lyon Community Education Kids Club. Child's Name Parent Name Parent Signature Date _
Health Statement. The proposed activity provided by the Angelina College Ropes Course, requires participation in physical exercises, which are, by their nature, physically demanding. Many of the activities will challenge you, and cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart related or other diseases. Therefore, all participants must be free of medical or physical conditions, which might create undue risk to themselves or any others who depend on them. Good physical condition will increase your enjoyment of the outdoor activities. If there is any doubt about your ability to safely participate in the experience, you should have a physical examination.
Health Statement. Neither Participant nor anyone in Participant’s household has tested positive for Covid-19 in the previous 10 days. Neither Participant nor anyone in Participant’s household has had close contact in the previous 14 days with someone who, within 48 hours before or 10 days after such contact, tested positive for Covid-19, suspected they had Covid-19 or showed symptoms of Covid-19. Symptoms of Covid-19 may include fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. Neither Participant nor anyone in Participant’s household has experienced any of the foregoing symptoms in the previous 10 days. In the event Participant or anyone in Participant’s household experiences any of the foregoing symptoms or is exposed to Covid-19, Participant will not return to the Club until cleared to do so by a healthcare provider. I have authority to enter into this Agreement on behalf of the above-referenced Participant and do hereby execute this Agreement on behalf of myself and Participant.
Health Statement. I understand that I am responsible for submitting a complete and accurate medical history on the forms provided by IPO or any follow-up forms required by IPO or my host institution, and I state that I have done so. I certify that I am free of medical conditions that would endanger my life, health, or well-being while traveling or living abroad, or that would impede my ability to fully participate in all aspects of the Program. I will follow my doctor’s advice on travel medicine, etc., and will follow the recommendations of the Centers for Disease Control (xxxx://xxx.xxx.xxx/travel/), provided that they do not conflict with my doctor’s advice, so that I will remain healthy on the program. I agree to take any medications, as prescribed, that are necessary to stay healthy, including medicines needed to manage mental illnesses or other chronic medical conditions. I also understand that if I do not make my medical or psychological needs known in a timely manner, IPO may delay my participation in the program until reasonable alternatives can be determined. I agree that if in the course of the program, the program director or the Director of Education Abroad determines in good faith judgment that the health, safety, welfare of myself or my fellow participants, or the integrity of the program experience, is jeopardized by my continued participation, I shall withdraw from the program and return to the United States, or be subject to expulsion. In such cases of medical withdrawal IPO will make every reasonable effort to ensure that I can receive partial credits or refund of program fees, where possible. ACCOMMODATIONS FOR DISABILITIES I understand that I am responsible for requesting reasonable accommodations related to a disability in a reasonable time frame prior to departure. I understand that I must provide IPO and University of Massachusetts Disability Services with any documentation required in conjunction with my request for accommodations. I further understand that legal and cultural expectations are not the same overseas as they are in the United States, and that my requested accommodations may not always be available at all overseas sites or programs, but that IPO will make every effort to ensure such accommodations are available. INTERNATIONAL TRAVEL & MEDICAL INSURANCE I understand that for the duration of my program and specific to the official program dates, I will be covered by the UMass Out-of- Country Accident & Emergency Sickness Medical Coverage. ...
Health Statement a. I hereby certify that my child is in good health. If the child has any activity restrictions, please list
Health Statement. Neither Camper nor anyone in Xxxxxx’s immediate family has suffered from or, to my knowledge, been exposed to COVID-19 within the past 45 days. Neither Camper nor anyone in Xxxxxx’s immediate family has experienced any of the following symptoms in the past seven days nor have they been on medication to alleviate any such symptoms in the past seven days: cough, sore throat, fever, shortness of breath, loss of smell and loss of taste. In the event Camper or anyone in Xxxxxx’s immediate family experiences any of the foregoing symptoms, I will notify the Club immediately and will not bring Camper back to the Club. I have authority to enter into this Agreement on behalf of the above-referenced Camper and do hereby execute this Agreement on behalf of myself and Camper. Signature of Parent/Legal Guardian: Click or tap here to enter text. Date: Click or tap to enter a date. May 31, 2021 EMERGENCY/MEDICAL TREATMENT Full name of Participant: Click or tap here to enter text. Participant’s Date of Birth: Click or tap here to enter text. Allergies: Click or tap here to enter text. Medications: Click or tap here to enter text. Medical History (ex., diabetes or epilepsy), Special Conditions/Needs: Click or tap here to enter text. Family Physician: Click or tap here to enter text. Phone: Click or tap here to enter text. Insurance Company: Click or tap here to enter text. Phone: Click or tap here to enter text. Group/Policy No: Click or tap here to enter text. Names of people to whom the Participant may be released. Click or tap here to enter text. Phone: Click or tap here to enter text. Click or tap here to enter text. Phone: Click or tap here to enter text. Click or tap here to enter text. Phone: Click or tap here to enter text. Completed by: Click or tap here to enter text. Date: Click or tap to enter a date. (Parent/Legal Guardian) PAYMENT INFORMATION Method of Payment: ☐ Member Charge (Member #: Click or tap here to enter text.) ☐ Check/Cash (paid on first day of camp) ☐ Credit Card Name on Card: Click or tap here to enter text. Credit Card Number: Click or tap here to enter text. Type of Card: Click or tap here to enter text. Exp. Date: Click or tap here to enter text. Security Code: Click or tap here to enter text. Billing Zip Code: Click or tap here to enter text.
Health Statement. The proposed activity provided by the Angelina College Ropes Course, requires participation in physical exercises, which are, by their nature, physically demanding. Many of the activities will challenge you, and cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart related or other diseases. Therefore, all participants must be free of medical or physical conditions, which might create undue risk to themselves or any others who depend on them. Good physical condition will increase your enjoyment of the outdoor activities. If there is any doubt about your ability to safely participate in the experience, you should have a physical examination. Participant Name: Male Female Age: Date of Birth: Street Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: TO BE COMPLETED WITH AN AC STAFF ONLY: I have discussed my health issues with a trained facilitator. My initials beside the following conditions are my consent to allow the facilitator to share said condition with other participants on the course for the sole purpose of keeping me safe. Staff signature: Participant signature: Name of Physician: Approx. Date of Last Exam: In an EMERGENCY, please notify (provide name & relation): Where will this person be during the time you will be on the course? (if at work, please provide name of business) Home/Cell Phone: Work Phone: HEALTH HISTORY: (Circle the appropriate answer and explain any YES answers) Have you had or do you currently have any heart problems (dates)? YES NO Do you frequently suffer from pains in your chest? YES NO Do you often feel faint or have spells of severe dizziness? YES NO Has a doctor ever told you that you have high blood pressure? YES NO (Note: If you have had any heart related problems or answered YES to any of the above questions you will need to have a release from a physician in order to go through a high elements training.) Are you a smoker?Do you have arthritis, joint or back problems that might be aggravated by exercise? Have you had any operations or serious injuries (dates)? Do you have any disabilities or chronic recurring illnesses or communicable diseases? YES YES YES YES NO NO NO NO Are there any activities to be limited/discouraged by physician's advice? YES NO Do you have Epilepsy? YES NO Do you have Diabetes? YES NO Are you allergic to any medicines, insects or pollen? (Circle all that apply & identify where necessary) YES NO Do you have asthma? If so, how often do you use ...
Health Statement. My child is in good health, with activity restrictions noted on the child information record. My child’s immunizations are up-to-date and on file with the school and/or appropriate waiver are on file with the school. Photo/Video Policy I understand that photos and/or videos are taken of children and that they may be published in Huron Valley School’s brochures, flyers, websites, HVTV, or other information material. Children’s names are never disclosed. PARENT NOTIFICATION OF THE LICENSING NOTEBOOK Child Care Organizations Act, 1973 Public Act 116 Michigan Department of Licensing and Regulatory Affairs All child care centers must maintain a licensing notebook which includes all licensing inspection reports, special investigation reports and all related corrective action plans (CAP). The notebook must include all reports issued and CAPs developed on and after May 27,2010 until the license is closed. ● This center maintains a licensing notebook of all licensing inspection reports, special investigation reports and all related corrective action plans. ● The notebook will be available to parents for review during regular business hours. ● Licensing inspection and special investigation reports from at least the past two years are available on the Bureau of Community and Health Systems website at xxx.xxxxxxxx.xxx/xxxxxxxxxxx. I have read the above statement issued by Huron Valley Schools School Age Care. Child(xxx)’s Name(s) Parent Name
