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3 years ago

preschool enrollment application

preschool enrollment application

John E. McCormac,

John E. McCormac, MayorWOODBRIDGE COMMUNITY CENTER600 Main Street, Woodbridge, NJ 07095Phone: 732-596-4170 Fax: 732-596-4187such materials of my child as an individual or part of a group with or without text to be used as part of Centeractivities.SIGNATURE _________ DATE ________________EMERGENCY TREATMENTAs parents or guardians of ___________________________, I _______________________ grant permissionand authorization to the Preschool at the YMCA at the Woodbridge Community for the following:1. A medical examination of my child, _________________, is required before admission to the Center,and at least once a year thereafter by a licensed physician. I understand that I must update the record of allillness and subsequent immunizations that occur after the initial examination.2. An accident or sudden illness to my child, __________________, will be treated on the premises ofthe Center by the staff with standard emergency first aid procedures. I understand that I will be notifiedimmediately, and will be required to pick up my child or send a reliable person in my place to be responsible fortaking my child from the Center to a designated place determined by me.3. Emergency treatment for my child, _____________________, will be obtained in my absence by theCenter Director and/or staff and its agents or for whatever kind of treatment is deemed necessary and is inhis/her best interest to protect the life/health and well-being of my child.4. I understand that any cost of services not reimbursable by insurance coverage shall be theresponsibility of the parents or guardian.5. A. If treatment beyond the standard first aid is required for the well-being of the child, he/she will betransported to a local area hospital.B. Transportation to a hospital/emergency service center will be made by necessary means to obtainmedical care or assistance for my child, __________________, as circumstances may require in the discretionof the Center staff, its employees or agents, is hereby authorized.6. If on a trip, I further authorize and give consent to any rescue squad or emergency assistancepersonnel and/or the closest medical facility personnel to render transportation or medical care as deemednecessary in their discretion, and in the best interest of the life, health, and well-being of my child.Having read and understood statements 1 through 6 above, I do hereby grant my permission, authorization,and consent to the above as long as my child is enrolled at the Preschool at the YMCA at the WoodbridgeCommunity, and until termination with at least one month notification.Parent Signature _______________________________Date___________________________

John E. McCormac, MayorWOODBRIDGE COMMUNITY CENTER600 Main Street, Woodbridge, NJ 07095Phone: 732-596-4170 Fax: 732-596-41874PICK-UP AUTHORIZATIONI/We, as parents of _______________________________ grant the authority to pick upsaid child from the Preschool at the YMCA at the Woodbridge Community. Please includeparent’s names.NAME ADDRESS PHONE RELATIONSHIP1. ______________________________________________________2. ______________________________________________________3. ______________________________________________________4. ______________________________________________________5. ______________________________________________________6. ______________________________________________________In order for the staff at the Center to release your child to any of the above persons, theoffice must be notified prior to pick-up. These persons must have identification whenentering the Center to pick up your child (ren).PARENT SIGNATURE _____________________DATE ____________

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