Flexible childcare

Child #1 Name *

First Name

Last Name

Child #1 Birthdate *

MM

DD

YYYY

Child #2 Name

First Name

Last Name

Child #2 Birthdate

MM

DD

YYYY

Guardian #1 Name *

First Name

Last Name

Guardian #1 Phone *

(###)

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Guardian #2 Name

First Name

Last Name

Guardian #2 Phone

(###)

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Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization *

This will serve as the complete authority for staff in the program to release my child(ren), listed above, into the custody of any of the persons whose names and telephone numbers appear below when notified in advance. This notification must be provided in advance: by myself or by either parent. It is understood that child/ren will not be released to anyone other than those listed here without written instructions from the parent. Children cannot be released to anyone under 12 years of age.

I understand that any person who is authorized to pick up my child must provide proper identification when it is requested by the staff.

Contact #1 Name *

First Name

Last Name

Contact #1 Phone *

(###)

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Contact #2 Name

First Name

Last Name

Contact #2 Phone

(###)

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Contact #3 Name

First Name

Last Name

Contact #3 Phone

(###)

###

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Forbidden Person #1 Name

First Name

Last Name

Forbidden Person #1 Phone

(###)

###

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Date of most recent Court Order

A copy of this must be kept in the child's file. Please email a copy to ece@durhamfamilyresources.org

MM

DD

YYYY

Physician's Name *

First Name

Last Name

Physician's Phone *

(###)

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Physician's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consent for Medical Treatment: *

If neither parent/caregiver can be reached, in case of an emergency, I understand that the staff members of the flexible childcare team are obligated to secure medical care for my child until I/we can be contacted. I give permission for members of flexible childcare team to give my child prescription and/or non- prescription medication that has been authorized by a dated note from my child’s doctor identifying my child’s name, the name of the medication, dosage, time of day medication is to be administered and the length of time medication is to be given. (Medications can only be administered if presented in original container with the prescription label indicating the above information. A signed Medication Form must accompany each medication to be administered). I give permission for members of the flexible childcare team to phone my child’s doctor, with my prior knowledge, as the need arises. I give permission to the members of the flexible childcare team to use and disclose my child’s personal information for the purpose of facilitating medical treatment pursuant to this consent.

I agree to the above statements

Consent Confirmation *

I hereby give permission for my child(ren) to participate in all activities of the program. I understand that enrollment in the Flexible Childcare Program means that my child(ren) may be observed and interacted with by students in the Early Childhood Education program as well as other programs of study under the supervision of Registered Early Childhood Educator and/or Director Approved Childcare Provider. I understand that the Flexible Childcare Program will record and maintain a file that includes personal information pertaining to my child(ren) for the purpose of providing appropriate care. I understand that personal information in this file is not disclosed except as required or authorized by law. By signing this document, I consent to this treatment of personal information. I consent to the use of audio and/or videotaping as well as still pictures for educational and/or promotional purposes. Individual identities of the children will be kept strictly confidential in any report or publication, including written and/or visual representations. In cases where a request is made to publish visual material externally, I understand that my additional consent will be requested prior to publication. I understand that the personal information provided will be used for the purpose of facilitating my child(ren)’s entry into the Flexible Childcare Program and to provide appropriate short-term, occasional childcare. By providing this information I consent to the use of personal information for these purposes.

I agree to the above statements

Any restrictions to use of pictures and/or videotape? *

No

Yes

Your Name *

Parent/Caregiver's Name

First Name

Last Name

Consent

In order to use the DFRFR Flexible Childcare Program, I (named above) agree to abide by the following conditions: I agree to fill in all required information in an accurate manner and will keep the information up to date. I agree to adhere to the drop-off and pick-up times I book my child(ren) for. The email to coordinate this with, is ece@durhamfamilyresources.org. I agree to pick up my child(ren) no later than the agreed time, and understand that a late fee of $5.00 for the first 15 minutes or portion thereof, $5.00 for the next 15 minutes or portion thereof and $1.00 a minute for any further time, will be charged. The late fee must be paid before I can use the Flexible Childcare program again. Repeated lateness will result in a warning and eventually I may be refused service. I agree to supply a healthy NUT FREE snack and drink, including prepared bottles for infants, diapers, a change of clothing and appropriate outdoor clothing for my child(ren). I will clearly label all of these items. The DFRFR EarlyON Centers are NUT FREE environments. I understand that I may not bring my child(ren) to the Flexible Childcare program if s/he is sick. f my child(ren) has been sick s/he must have been fever-free for at least 24 hours prior to attending the Flexible Childcare program. I also understand that if my child has diarrhea, or any other gastrointestinal sickness s/he is not allowed to attend the Flexible Childcare program until 48 hours after the child is symptom free.

I agree to the above statements