FAMILY INFORMATION
Child’s Last Name: First Name:
Birth Date:
Home Phone:
Guardian 1 Name: Email:
Work Phone: Cell Phone:
Guardian 2 Name: Email:
Work Phone: Cell Phone:
EMERGENCY CONTACTS
Contact 1: Phone: Relationship:
Contact 2: Phone: Relationship:
HEALTH INFORMATION
Health Card No.: Expiry:
Family Doctor: Street Address: Phone Number:
Dentist: Street Address: Phone Number:
Allergies & Medications:
Does your child have any known allergies?
Is the allergy serious enough to require medication or emergency treatment?
If yes, please describe in detail:
Is your child on any medications?
If yes please list:
Is your child toilet trained?
The following authorization is between (herein called the
Family) and Joyful Learning Center Ltd.
MEDICATION AUTHORIZATION
1. I agree to provide Joyful Learning Center staff with:
a. In the case of Non-prescription Medication
i. All medications must be provided by the parent or guardian in the original container with the original label. They must have child proof-capping and be identified with the dosage and the name of the child for whom the medication is intended.
b. In the case of Prescription medication
i. Prescription medications must have (in addition to the above) the name of the physician or doctor; instructions; and the time period of use.
c. Photograph – in the case of epinephrine auto-injectors
i. ONE photograph that will be affixed to the Medication Administration Request Form.
d. Inform staff of allergy, emergency treatment and location of EpiPen, EpiPen must be prescribed by a physician and labeled with the pharmacist and child’s name.
2. Joyful Learning Center will refuse to care for a child who requires the use of emergency medication (i.e., Nitroglycerin, inhaler, EpiPen) and comes to the program without their medication.
3. I agree that Joyful Learning Center staff may refuse to administer, supervise children taking their own medication, or store medication where the labels on the medication container(s) do not contain all the information specified above.
4. I understand that not all Joyful Learning Center staff are trained health professionals, and that the administration of medication is being provided by or, on behalf of Joyful Learning Center on a purely voluntary and gratuitous basis. As the Participant or Parent/ Legal guardian of the Participant/Client receiving medication, I fully understand the nature and extent of the risks involved in administering medication.
I confirm that I have read, understood and completed the medical conditions and the registration form.
I am aware that by signing this agreement I have agreed to assume full legal liability for all risks involved in having Joyful Learning Center administer medication under form this to the named kid.
EMERGENCY AUTHORIZATION
In the event of an emergency, I authorize the staff of Joyful Learning Center to act on our behalf and give consent to any medical treatment for my child, . This consent is only exercised if attempts to reach us at the phone numbers provided are unsuccessful.
PICK-UP AUTHORIZATION
I give permission for Joyful Learning Center to pick up my/our child/children in the bus stop located at Unit 103, 37 Ella lane, Bedford, NS B4B 2J6.
Please list the names of people, other than the child’s parents, who you permit to pick up your child from Joyful Learning Center in your absence. Please note these authorized people will be asked to show photo identification if the attending child care staff member is unfamiliar with the person picking up your child.
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Name: Relationship:
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Name: Relationship:
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Name: Relationship:
PHOTOGRAPH PERMISSIONS
I allow my child to be photographed or videotaped for promotion of programs and services on the public website, in print, or electronic media.
ACTIVITY PERMISSIONS
I give permission for my/our child/children to walk to and/or participate in activities geared for my child/children in the flowing location under the supervision of the provider.
Location 1: Unit 103, 37 Ella lane, Bedford, NS B4B2J6
Location 2: Unit 203, 38 Ella lane, Bedford, NS B4B1S8
Location 3: Joyful Outdoor Playground: Northwest side of the 12 Ella Ln Building
Location 4: Brookline Drive Park: 210 Brookline Drive, Bedford
Location 5: Cascades Community Playground: Evandale Ln & Abbington Ave
GUARDIAN WAIVER AND RELEASE OF LIABILITY FORM
CONSENT AND WAIVER OF LIABILITY
In consideration of (name of child) being permitted to participate in the Joyful Learning Center After School Programs, I, , the undersigned parent or legal guardian of the Child, on behalf of myself, my heirs, executors, administrators, and assigns, hereby:
1. Understand, appreciate and accept the inherent physical risks of the After School Program, including that serious injury is possible and may result from my child’s actions, the actions or interactions of others, or a combination of both.
2. Understand, appreciate and accept the inherent risk of exposure to COVID-19 that exists by attending the After School Program and agree to comply with all directives from After School Program staff related to COVID-19, including all requirements for social distancing.
3. Agree to be solely responsible for any personal property loss or damage, and/or any personal injury sustained by my child unless such loss, damage or injury was caused by sole negligence of Joyful Learning Center, its employees or agents.
4. Have read, understand, and discussed the After School Program Code of Conduct with the participant. I understand that failure to comply with the After School Program Code of Conduct may result in my child being suspended and/or removed from the After School Program.
5.Give permission for my child to participate in the After School Program.
CONFIDENTIALITY AGREEMENT
Information regarding children, parents, staff or volunteers shall be respected and handled confidentially. All information concerning children, parents, staff or volunteers shall be confidential and shall not be disclosed to or discussed with anyone other than those authorized to receive such information, unless disclosure is authorized by law. Failing to abide by this agreement could result in termination. This applies to children, parents, staff or volunteers. I confirm that I have read, understood and will, comply with the above directive on Confidentiality.
FINAL AGREEMENT
