Registration Form. Full Name. Address. Phone Numbers (H)

Transcription

1 Registration Form Parent Information Parent 1 Full Name Address Phone Numbers (H) (C) (W) Address *Would you like to receive s to this address about special promotions/events at The Drop Zone? Yes No Parent 2 Full Name Address Phone Numbers (H) (C) (W) Address *Would you like to receive s to this address about special promotions/events at The Drop Zone? Yes No

2 Children Child s Name & Nickname Sex Child s Age Allergies? (Last name, if different) 1. M/F 2. M/F 3. M/F 4. M/F 5. M/F Emergency Contact 1. Name Relationship to Child Contact Phone Number (H) (C) 2. Name Relationship to Child Authorization to Pick-Up Please list the name of ALL adults that you would allow to pick-up your child(ren). Please note that anybody picking up the child(ren) must show valid identification. Name Relationship to Child Phone Number

3 The Drop Zone- Drop-In Child Care Center, LLC Emergency Medical Contacts and Consent for Medical Treatment: In the event I cannot be reached, I, or whoever signs my child in for that day (Authorized Representative to act as an agent for me), give my permission for The Drop Zone to provide basic first aid to my child as reasonably appropriate, however, I understand The Drop Zone shall not be required to strictly follow those guidelines when, in its judgment, circumstances may require otherwise. In the event that The Drop Zone, in its sole discretion, believes that my child needs more advanced care, I consent to dental, medical, surgical, and/or hospital care, treatment, and/or procedures to be performed for my child by a licensed dentist, physician, ambulance attendant/emergency medical technician, or other licensed health care provider (collectively, Health Care Professional ) associated with a licensed treatment facility when deemed necessary or advisable by the Health Care Professional to safeguard my child s health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or The Drop Zone to an emergency center for treatment. I certify my child is in excellent health and physical condition and has no medical, psychological, physical or mental condition which has not been disclosed to The Drop Zone on the registration form. My child(ren) does not have any infectious, contagious or communicable diseases. In the event my child is in need of emergency care, I do not require that the following physician or hospital be contacted. The information provided below is for informational purposes only. I consent to my child being taken to the treatment facility recommended by the Health Care Professional attending my child. Name of Physician Office Address Phone Number Name of Hospital Address Phone Number Parent Signature Date

4 I represent that I am the parent or legal guardian of each child designated on this registration form. I, on behalf of myself, my spouse, and each child designated on the registration form (my child ), hereby waive and release all rights, causes of action and claims against this independently owned/operated The Drop Zone- Drop-In Child Care Center, L.L.C.(The Drop Zone), its Officers, Directors, Agents, and Employees and all of its affiliates, for any loss, expense, damage or injury suffered by my child during the time my child is visiting The Drop Zone, including the possible negligence of the Drop Zone, but excluding gross negligence and intentional misconduct. I understand that the provision of child care contains risk of injury to persons and damage to property, and that by signing this release I engage The Drop Zone to provide temporary childcare for my children at my own risk. I have been given an opportunity to inspect the premises of The Drop Zone and found that it is safe and satisfactory for my child. I also have been given the opportunity to ask questions and obtain answers to my satisfaction regarding any and all aspects of the Drop Zone and this Release. By signing this Release, I have not relied on any promises or statements made by The Drop Zone or its employees other than those contained in written information supplied to me by The Drop Zone. I understand this Release will be kept on file at The Drop Zone and will continue in effect for this and any future visits my Child may make to The Drop Zone. I have read the above carefully and fully understand the content and consequences of this agreement and agree to abide by and be bound by the above policies and procedures and release. Parent Signature Date Parent Policy and Release Form Drop Off & Pick Up Policy A completed registration packet and health history form must be on file before a child can be accepted into The Drop Zone for care. Once a completed registration packet and health history form is on file, the parent or authorized adult will sign the child(ren) in. A While I m Away form is required to give staff specific instructions, if needed. A short health inventory is required at each visit to assess the child s current health. A staff member will check the parent or authorized adults I.D. and a code word will be given. A deposit of one hour of care will be collected. At pick-up, staff will check I.D. and ask for code word. If you must send a different person to pick up your child, please relay the code word. A staff member will give an overview of your child s visit and collect your remaining balance, including any fees for snacks or meals provided, and/or diapers. Hours

5 The Drop Zone is open 7 days a week. Monday-Thursday 8:00 am-10:00pm; Friday-Saturday 8:00 am- 11:00 pm; Sunday 11:00 am-7:00 pm. Children are allowed to be at The Drop Zone for no more than 4 hours. At closing, you will be charged $1.00 for each minute that you are late. After 15 minutes, staff will attempt to contact the parents. If parents cannot be reached after 15 minutes, children will be turned over the local police department. We advise that you call as soon as possible if something happens that causes you to arrive after the center has closed for the night. While we cannot waive the late fee, it will prevent a phone call to the local authorities. Meals & Snacks Because The Drop Zone accepts children all day, we have not set a snack/meal schedule. Better yet, when you drop your child off, we ask that you complete the While I m Away form which will let us know if and when your child(ren) need to have a meal or snack. We recommend that you pack and label whatever your child will need, however, we do provide snacks and meals for an additional fee. A snack is offered for an additional $2.00. A bag lunch can be purchased for $3.50. Any food brought into the center must be nut-free. If any food containing nut products is brought into the center, we will discard of it and provide the child with one of our bag lunches or snacks. The safety of all children is our number one concern and we apologize for any inconvenience. Diapering You must clearly communicate to staff if you have a child still in diapers. The While I m Away Form will allow you to do so, as well as inform the staff of your child s last diaper change. If you forget to bring diapers, or if your child runs out while in our care, we can provide diapers for an additional fee of $1.00 per diaper. Personal Belongings Your children may not bring their personal toys and/or electronic gadgets to The Drop Zone. We are not responsible for lost/damaged toys that are brought to the center. Discipline Policy At the Drop Zone, we want children to enjoy themselves in a safe, positive environment. At any time the staff feel as though a child s behavior causes a distraction and/or could possibly harm other children, they will take disciplinary action. There are 3 steps in The Drop Zone s Discipline Policy and are outlined below: Step One: Verbal Warning Staff will issue a warning to the child. Once a child demonstrates a behavior that requires discipline, the

6 staff member will pull the child aside and explain the behavior that they observed, and kindly ask the child to refrain from continuing to exhibit such behavior. This is considered their verbal warning. Step Two: Timeout Once a child has been given a verbal warning and continues to exhibit negative behavior, they will be placed in a short timeout. Timeout is simply a few minutes spent sitting, not allowed to participate in any activities. The time children sit out is based on their age: example: 2 yrs. old= 2 minutes of timeout Step Three: Call to Parent/Guardian If the behavior problem continues, a staff member will call a parent/guardian or any authorized adult to come and pick up the child. **Please note that if the behavior problem is extremely severe, we will call a parent/guardian immediately. There is a zero tolerance for extreme behavior problems. Discrimination Policy The Drop Zone does not discriminate on the basis of gender, race, color, religion, or national origin. However, we reserve the right to refuse service to any person or persons for legitimate business reasons, such as maintaining the safety of our facility and the children in our care. The Drop Zone does not discriminate against persons with disabilities. However, The Drop Zone staff are not trained to care for children with special needs and our services do not include one-on-one supervision Sick Child & Medicine Administration Policy The Drop Zone cannot accept children who are ill. Children must be fever-free and symptom-free for at least 24 hours before visiting The Drop Zone. We cannot administer any medication or routine medical procedures (i.e. inhalers, nebulizers). No medications are permitted in the center. In the event that a child becomes ill, the parent or emergency contact will be called to pick up the child immediately. Children who are ill will be excluded from other children until parent pick-up. Mandated Reporters The Drop Zone staff is mandated by law to report any signs of child abuse and neglect. In Maryland, the child abuse and neglect law requires that anyone who SUSPECTS a child has been or is being mistreated must report the matter to the Department of Social Services.

7 I have read the above carefully and fully understand the content and consequences of this agreement and agree to abide by and be bound by the above policies and procedures and release. Parent Signature Date