OnFarm Childcare

Child No. 1 - Info *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Child No. 2 - Info

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child No. 3 - Info

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child No. 4 - Info

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is your relationship to the child(ren)? *

Parent

Legal Guardian

Other

Same address as child(ren)? (If no, address/city/postal code): *

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Work Phone *

(###)

###

####

What is your relationship to the child(ren)? *

Parent

Legal Guardian

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Work Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Work Phone

(###)

###

####

Has the child(ren) had all their immunizations? (must provide copies of all children's immunization records): *

Yes

No

Allergies to food, medication or materials? (if 'yes', provide more info below): *

Yes

No

Skin conditions? (if 'yes', provide more info below): *

Yes

No

Is your child(ren) under any form of treatment/medication for illness or injury?: *

Yes

No

Does you child(ren) have any health concerns that will interfere with their participation in activities while under DFRFR Staff supervision?: *

Yes

No

I hereby authorize the Caregiver to administer any medication that appears on the medication form that is signed by me, according to instructions on the form. *

Yes

No

I hereby authorize the Caregiver or a representative of DFRFR to consent to emergency care from other qualified sources, should they believe a medical emergency exists and they cannot contact me in a reasonable time for further instructions. *

Yes

No

I hereby release DFRFR and the Caregiver from all liabilities for any complications that may arise as a result of care given in accordance to my instructions. *

Yes

No

I hereby authorize DFRFR to use photographs in which I and/or my child(ren) appear for use in promoting DFRFR's programs and membership to the general public. This may include (but is not limited to) newsletters, annual report, publicity materials, display materials and news articles. *

Yes

No

I give consent for my child(ren) to use a 70- 90% hand sanitizer as necessary, applied under adult supervision. *

Yes

No

I have read the DFRFR Information Booklet and agree to comply with all aspects as outlined. *

Yes

No

I have read the DFRFR Booking Procedures and Fee Structure and agree to comply with all aspects as outlined. *

Yes

No

The Purpose of the Organization: *

a) To establish and maintain programs and facilities & resources for rural families and their children b) To provide seasonal, quality and flexible childcare services to farm families. c) To gather and exchange ideas and information to assess the changing childcare needs of rural families in the Region of Durham.

I have read and agree with the above purpose of the organization and agree with Durham Farm and Rural Family Resources.