Child #1 Name
*
First Name
Last Name
Child #1 Heath Card
*
Child #1 Birthdate
*
MM
DD
YYYY
Child #2 Name
First Name
Last Name
Child #2 Heath Card
Child #2 Birthdate
MM
DD
YYYY
Guardian #1 Name
*
First Name
Last Name
Guardian #1 Phone
*
(###)
###
####
Guardian #1 Email
*
Guardian #2 Name
First Name
Last Name
Guardian #2 Phone
(###)
###
####
Guardian #2 Email
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.
Contact #1 Name
*
First Name
Last Name
Contact #1 Relation To Child(ren)
*
Parent
Grandparent
Aunt/Uncle
Neighbour/Friend
Contact #1 Phone
*
(###)
###
####
Contact #2 Name
First Name
Last Name
Contact #2 Relation To Child(ren)
Parent
Grandparent
Aunt/Uncle
Neighbour/Friend
Contact #2 Phone
(###)
###
####
Contact #3 Name
First Name
Last Name
Contact #3 Relation To Child(ren)
Parent
Grandparent
Aunt/Uncle
Neighbour/Friend
Contact #3 Phone
(###)
###
####
Forbidden Person #1 Name
First Name
Last Name
Forbidden Person #1 Relation To Child(ren)
Parent
Grandparent
Aunt/Uncle
Neighbour/Friend
Forbidden Person #1 Phone
(###)
###
####
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
*
(###)
###
####
Physician's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Does your child(ren) have any allergies or require an EpiPen?
*
Please list any details as necessary including any special considerations or instructions for the childcare team:
Does your child(ren) have physical limitations?
*
Please list any details as necessary including any special considerations or instructions for the childcare team:
Does your child(ren) have any chronic health problems or medical conditions or require medication while in care? *If medication is required during childcare, a request to administer medication form must be signed by a parent/guardian before the child can attend flex care*
*
Please list any details as necessary including any special considerations or instructions for the childcare team:
Is your child toilet trained or training?
*
Please list any details as necessary including any special considerations or instructions for the childcare team:
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.
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.
Any restrictions to use of pictures and/or videotape?
*
If yes, please specify:
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.
