2015 Sideburn Run Childcare Authorization Form printable pdf download

2015 SIDEBURN RUN

Childcare Authorization Form

Member #_________

MEMBERS’ NAME:________________________________________________________________

Home Phone:_____________________ Work Phone:_____________________________________

Cell Phone:_______________________Other Phone:_____________________________________

CHILDCARE PROVIDER NAME:_____________________________________________________

Address:_________________________________________________________________________

Home/Cell Phone:_______________________________________ Age: ______________________

The childcare provider:

•

Must be at least 16 years old.

•

Must be familiar with Sideburn Run’s pool rules.

•

Is not allowed to bring provider’s own child/children while caring for Members’ children.

•

Cannot access the pool except in official capacity as a childcare provider unless status

shows “Live-in” (proof of residency required).

•

“Live-In” provider can use the pool unaccompanied by Sideburn Run’s Pool Member’s

child/children but cannot sign-in guests or own family members.

CHILDREN UNDER SUPERVISION OF SITTER

Name

Age

Name

Age

Members are responsible for the conduct of their children who attend the pool accompanied by a

childcare provider, as well as for the conduct of the above named childcare provider. It is the

members’ responsibility to insure that the pool management has an accurate phone number to

reach the parents or authorized individual.

Sideburn Run Recreation Association will not be held responsible for any loss of property or

personal injury.

SRRA cannot accept responsibility for the health and medical care of Members’ children and their

childcare provider. SRRA does not maintain or administer emergency medicines or equipment

(such as epi-pens or cardiac equipment). If Members’ children or childcare provider has a medical

condition which would require the use of such medicines or medical devices, Member is solely

responsible for providing, carrying and directing childcare provider to administer such

medicines/medical equipment. In cases of medical emergencies, lifeguards of the Pool are

directed to call 911.

Non-member Childcare providers may be added to family memberships only for a fee of $25

each (no discounts for age). Please submit a check made payable to SRRA with this form. Fee

is non-refundable.

Member’s Signature: _______________________________ Date____ ____________

2015 Sideburn Run Childcare Authorization Form