Parental Emergency Medical Consent Form (Page 2 of 2) in pdf

Names of additional person authorized to pick up the child.

Name ________________________________Relationship_______________ Phone #_____________

Alternate address

Correspondence will be sent to the first parent/guardian on the opposite page unless noted here.

__________________________________________________________________________________

Travel and activity authorization

I ___do / ___ do not give permission for my child to Five Seasons Learning Center for trips in a car or on

public transportation to special places, etc. I understand that I will be notified before each such field trip. In

the case of public transportation, no seat belts are available. Only children 3 years and older will take field

trips. One additional staff always accompanies each group, and the staff have a cell phone and first aid kit

along with emergency phone numbers for each child.

I ___do / ___do not give permission for my child to leave Five Seasons Learning Center for walks around

the neighborhood. I understand that I will not be notified before each walk.

Photo Release

I ___do / ___ do not give my consent to let my child be photographed for use by Five Seasons Learning

Center in newspapers or other media for the purpose of publicity or advertisements.

Sunscreen, ointments and/or insect repellent containing DEET

I ___ do / ___do not give Five Seasons Learning Center permission to use sunscreen, first aid antiseptic

ointment, or insect repellent on my child.

___ My child is allowed to apply sunscreen by him/her self.

___The staff must apply sunscreen on my child.

DHS guidelines require each child to have his/her own bottle of sunscreen/insect repellant. Please

be sure to label the bottles with your child’s name.

10. Swimming (School Age Only)

___ My child needs to be in the shallow end of the pool (0-3’).

___My child may swim in the 3’-5’ (3’-6” at Cherry Hill) area of the pool. (I understand that the children are

not allowed to swim in the deep end of the pool or dive off the diving board. )

___My child is allowed to use the water slide in the pool.

___My child is NOT allowed to use the water slide in the pool.

11. Allergies

___ My child has allergies that are listed on the intake form. I give permission for staff to post this

information as a visual reminder to all staff.

___________________________________________________

________________

Signature of Parent/Guardian

Date

3580.0007

7/12

Parental Emergency Medical Consent Form Page 2