CHILD DISCOVERY TIME EMERGENCY CARD FOR OFFICE FILES ...

AUTHORIZATION FOR EMERGENCY MEDICAL CAREI hereby give my permission to Child Discovery Time staff to call a doctor or emergency medical service, and forthe doctor, hospital, or medical service to provide emergency medical or surgical care for my child,______________________________________________, should an emergency arise.(Name of Child)It is understood that the Child Discovery Time staff will make a conscientious effort to locate the emergencycontacts listed on the emergency card (located on flipside of this card) before any action will be taken. If it is notpossible to locate emergency contacts listed, I/we will accept the expense of emergency medical or surgicaltreatment.Signature (s) of Parent (s) or Guardian (s)__________________________________________Date: __________AUTHORIZATION FOR EMERGENCY MEDICAL CAREI hereby give my permission to Child Discovery Time staff to call a doctor or emergency medical service, and forthe doctor, hospital, or medical service to provide emergency medical or surgical care for my child,______________________________________________, should an emergency arise.(Name of Child)It is understood that the Child Discovery Time staff will make a conscientious effort to locate the emergencycontacts listed on the emergency card (located on flipside of this card) before any action will be taken. If it is notpossible to locate emergency contacts listed, I/we will accept the expense of emergency medical or surgicaltreatment.Signature (s) of Parent (s) or Guardian (s)__________________________________________Date: __________

CHILD’S HEALTH RECORDChildren who enroll in child care programs must submit a signed and dated statement of thechild’s current health status which indicates the child’s abilities and/ or limitations to participatein a regularly scheduled program of play in a group of young children. This report is to be filledout by a licensed physician or a licensed nurse practitioner that has seen the child in the lasttwelve months.Health Record for _______________________________________________________________Name of Facility/Type of ProgramChild’s Name_______________________________ Sex______ Birth Date_________________Address_______________________________________________________________________Past Illnesses---Check those that the child has had and give approximate dates:Chicken Pox_________________ Rubeola_________________ Rubella____________________Rheumatic Fever_____________ Asthma_________________ Hay Fever__________________Diabetes ___________________ Mumps__________________ Epilepsy___________________Whooping Cough_____________ Poliomyelitis_____________ Other______________________This child is_________ is not_________physically or emotionally able to participate is the daycare program named above.Comments: ____________________________________________________________________Surgery/Accidents/Illnesses/Chronic or Handicapping Problems: ________________________________________________________________________________________________________________________Describe any physical condition requiring special attention by center staff: ______________________________________________________________________________________________________________________________________________________________________________________________________Medication(s) prescribed: ________________________________________________________________Allergies that staff should be aware of: __________________________________________________ andPrescribed routine: ______________________________________________________________________If tuberculin test given: Date ____________________________ Result ___________________________If chest X-ray taken: Date ____________________________ Result ___________________________Vision______________________________________ Hearing____________________________________Please record immunizations and dates administered on the Colorado Department of Health Certificate ofImmunization and attach it to this form.Date of most recent examination of child: ____________________________________________________Signature of Licensed Physician or Licensed Nurse Practitioner:________________________________________________________Date__________________________Please print name and address of physician: ________________________________________________________________________________________________Child Discovery Time’s Fax number is 303 730-2654

WAIVER AND RELEASE FROM LIABILITYAND AGREEMENT TO INDEMNIFYAS PART OF PARTICIPATION in the activity or event conducted by SOUTH SUBURBANPARK AND RECREATION DISTRCIT (“District”), the undersigned hereby agrees as follows:1. The undersigned is authorized to make this Release on behalf of the person, party,group, or organization he represents.2. The undersigned HEREBY RELEASES, WAIVES, DISCHARGES, INDEMNIFIES,AND COVENANTS NOT TO SUE THE DISTRICT, officers, officials, andrepresentatives on account of injury to person or property while the undersignedand/or the persons he represents are participating in the District’s activity or event.3. By registering for any program, registrant acknowledges that the program activities carrycertain risks for the participants. Further, by registering, registrant releases andindemnifies District, its employees, agents, contractors, or volunteers from and againstany and all claims, demands, loss or injury to person or property, caused duringparticipation in the activity. This release and indemnity is intended to be as broad aspermitted by law.4. The undersigned expressly agrees that the foregoing release, waiver, andindemnifying agreement is intended to be as a broad and inclusive as is permitted bythe law of the State of Colorado, and further that if any portion thereof is held invalidthe remainder of this agreement shall continue in full legal force and effect.THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE ANDWAIVER OF LIABILITY AND INDEMNITY AGREEMENT on behalf of himself/herself and the person,Group or organization, and further agrees that no oral representations statements or inducements have beenmade._________________________________________________________Date_____________________RELEASING PARTY

RELEASE FORM LIABILITY STATEMENTI understand that my child, __________________________________, is participating inChild Discovery Time through South Suburban Park and Recreation District. I am awareThat in an active program such as this, there are risks, which are inherent in the activity.IAm willing to assume these risks for my child and further will hold South Suburban andits employees harmless from any such injuries which may result in the normal course ofProperly supervised activities. I, also, understand that although some activities areSponsored by South Suburban and Recreation District, it is being conducted, at least inPart, on premises not owned or operated by the District. I hereby acknowledge that,under such circumstances, the District shall not be liable for injuries or harm incurred as aresult of my child’s participation in this activity and I hereby agree to release and hold theDistrict and its employees harmless from any and all liability relating to injuries or harm,to person or property, which occurs on any premises not owned or operated by theDistrict. This waiver and release shall be binding on my heirs, successors and assigns.Signature (s) of Parent (s) or Guardian (s)____________________________________________________________________________________________Date____________________________________AUTHORIZATION TO PARTICIPATE OR EXCLUDE PARTICIPATION INCHILD DISCOVERY TIME ACTIVITIESI hereby give permission for my child to go on trips away from South Suburban whetheron foot or by vehicle.I give permission to have my child photographed by the company taking pictures for theChild Discovery Time Program. I, also give permission to have my child’s picture takenby the Child Discovery Time Staff for various art activities.I give permission for my child to participate in all Child Discovery Time activities withthe following exceptions: __________________________________________________Signature (s) of Parent (s) or Guardian (s)______________________________________________________________________________________________Date____________________________________

Dear Child Discovery Time Parents:Welcome to Child Discovery Time . ... And the beginning of an exciting journeyinto the world of learning.Just a reminder the remainder of tuition for fall is due by June 1st,*Failure to make payment for the fall classes by the due Date will resultin forfeiture of your space.2012 – 2013 School Year – Begins August 20, 2012I am sending everyone an Enrollment packet for the upcoming 2012-2013+ fall year,which includes:1) Enrollment card,2) Waiver form,3) Emergency cards,4) Health record sheet which must be filled out and signed by the doctor,5) Immunization card which must be filled out and signed by the doctor (or) aprintout provided by your doctor that is approved by CDPHE, entitled ColoradoAlternative Certificate of Immunization and signed by the doctor.The last two documents are Colorado Department of Public Health and Environmentrequirements for a child to enter the Preschool.This year the Child Discovery Time staff would like to invite you to our OpenHouse. Thursday, August 16, from 1:30 to 2:30 p.m., in Rooms 4 & 5.At this time you and your children are welcome to come and meet your child’steacher and teacher’s aide, you may also see the classroom that they will be infor the year.Please bring your completed enrollment forms that I am mailing to you. All formsmust be filled out and completed the first day of school.Supply ListOn Your Mark/Marv. 2 ½ & 3 year olds9- Swim Diapers1- Box of Unscented Wipes1 – Glue Bottle – 8 oz.Fabulous 3 & 4 Year olds/Ready, Set, Go!1 - Box Water Colors1 – Box of Markers1 – Glue Bottle – 8 oz.1 – Box CrayonstogsdiWell See You Then,Cindy Stogsdill - Child Discovery Time - Director

MEDICATION ADMINISTRATION IN THE CHILD DISCOVERY TIMEPRE- SCHOOL PROGRAMThe parent/guardian of ______________________________ ask that Child Discovery Time(Child’s Name)Staff give the following medication________________________________ at _______________(Name of Medicine and dosage)(Time(s)to my child, according to the Health Care Provider’s signed instructions on the lower part of thisform.The Program agrees to administer medication prescribed by a licensed health care provider.It is the parent/guardian’s responsibility to furnish the medication.The parent agrees to pick-up expired or unused medication within one week of notification byStaff.Prescription Medications must come in a container labeled with: child’s name, name of medicine,Time medicine is to be given, dosage, date medicine is to be stopped, and licensed health care provider’sname. Pharmacy name and phone number must also be included on the label.Over the counter medication must be labeled with child’s name. Dosage must match the signedHealth care provider authorization, and medicine must be packaged in original container.By signing this document, I give permission for my child’s health care provider to share informationabout the administration of this medication with the nurse or school staff delegated to administerMedication._________________________________ _________________________________ _____________Parent/Legal Guardian’s Name Parent/Legal Guardian Signature Date__________________________________Work Phone_________________________________________Home PhoneHEALTH CARE PROVIDER AUTHORIZATION TO ADMINISTER MEDICATION IN THECHILD DISCOVERY TIME PRE-SCHOOL PROGRAMChild’s Name:___________________________________________Birthdate:_______________________Medication:_____________________________________________Dosage:____________________________Route________________To be given at the following time(s):________________________________________________________Special Instructions:______________________________________________________________________Purpose of Medication:___________________________________________________________________Side effects that need to be reported:_________________________________________________________Starting Date:_____________________________________Ending Date:____________________________________________________________________________ ____________________________________Signature of Health Care Provider with Prescriptive Authority License Number__________________________________________________ ______________________________Phone NumberDatePlease ask the pharmacist for a separate medicine bottle to keep at school/child care.Thank You!