Name * First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational E-mail * General I give the teachers in the School Age Child Care Program permission to take my child on walking trips with their class near the center. My child also has my permission to play on all the equipment both inside and outside. I am fully aware the teachers will supervise my child while they are using the equipment. My child has permission to be in the yard next to Kid’s Café for eating purposes or short activities requiring a grassy area. The School Age Child Care Program Director or next in charge has my permission to administer medications to my child according to the Department of Early Education and Care (EEC) standards. This includes a signed Authorization Form by me and the physician showing the specific medication, date, dosage, amount, and times the medication will be administered, and all medication is in the original package with the label. I understand the staff will keep an accurate record of all medication, provided it is given according to written instructions. If an ambulance should be called in an emergency, I agree to pay all costs incurred and for all resulting care. In an emergency, I understand The School Age Child Care Program Director and/or Assistance Director will accompany my child to the hospital. They also have the permission to act as “loco parentis” if they cannot reach my family members. I understand an attempt to locate myself, spouse, or designee will continue from the hospital until I am reached. I also promise to keep current telephone numbers, addresses for work, home, and school up to date. The Emergency Contact Release Form my child will be kept current as well. My child has permission to participate in activities in the Clark University Field. I Agree to all the above statement and fully understand my responsibilities as outline. * Yes No Photograph / Video Tape / Media Permission I give permission for my child to be: Photographed/videotaped by The School Age Child Care Program at The Boys and Girls Club of Worcester Projects. * Yes No Used in public relation materials for the School Age Child Care Program at The Boys and Girls Club of Worcester and partner organizations or companies associated with The Boys and Girls Club of Worcester website, You Tube, Club’s Facebook page, and Club’s Twitter page. * Yes No SwimmingI give my child permission to: Swim in The Boys & Girls Club Of Worcester Swimming Pool with the School Age Child Care Program with the understanding that my child will be supervised by the School Age Child Care Program staff and Certified Lifeguard/Swim Instructor. * Yes No Parent /Guardian Signature Signer Name * Signer Title * This form is in effect one (1) year from the date of my signature and good only while my child is enrolled at The Boys & Girls Club of Worcester School Age Child Care Program.
