Peak Child Care Agreement - St. Irene Catholic School printable pdf download

PEAK CHILD CARE AGREEMENT

St. Irene School

Warrenville, Illinois

Child’s Name ___________________________________

Birth Date ____________

Parents’ Names ____________________________ ______

Phone ________________

Person Authorized to Pick Up Child __________________________ Phone ________________

Restraining Order in force? Yes _____ No _____

Name of Person: ___________________

Emergency Contact Person________________________________ Phone _________________

Name of Physician ______________________________________ Phone _________________

Address of Physician ____________________________________ City ___________________

Hospital Preference _____________________________________________________________

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Dates and Times of Care _____________________________________________________

1. Does child have any medical condition necessitating dietary supplements or restrictions, medications

or avoidance of allergies? Yes _____ No _____

2. Are Immunization Records current? Yes _____ No _____

3. Is there a Health Exam Form on file? Yes _____ No _____

4. Are there any restrictions on normal physical activities? Yes _____ No _____

If “Yes” please specify: __________________________________________________

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

1. A child who appears ill upon arrival at PEAK shall not be allowed to stay in PEAK.

2. At time of registration, parents should authorize the child’s physician to accept calls from

the PEAK caregiver for any emergency or medical care.

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

I hereby authorize St. Irene School to take my child to the above named physician or facility for medical treatment

in the event of an emergency in which neither parent can be reached. If the above named physician cannot

respond, I authorize any licensed physician or medical center to treat my child.

____________________________________________

_____________________________

Parent / Legal Guardian Signature

Date

_____________________________________________________________

__________________________________________

Parent / Legal Guardian Signature

Date

Peak Child Care Agreement - St. Irene Catholic School