The following agreement is between:
________________________________________ _______________________________________
Parent/guardian/caregiver Phone number(s) to best be reached
________________________________________ _______________________________________
Home address Mailing address if different
________________________________________ _______________________________________
Emergency contact, relation Phone number
Email address: ____________________________________________________
And St. John’s Episcopal Church
Childcare services will be provided by St. John’s Episcopal Church for the following child/ren:
1.____________________ Birthdate ____________________
2.____________________ Birthdate ____________________
Requested donation is $25 per child for drop in, $45 for two children
or $20 per child monthly sign-up, $35 for two
(All rates are per day)
If you are unable to pay this amount, please mention it to Kari.
Medical Information:
__________________________________________ _______________________________________
Physician’s name/number Name/number
__________________________________________ _______________________________________
List all known medical conditions including food and drug allergies. Also list any and all over-the-counter and/or prescription drugs taken regularly
__________________________________________ _______________________________________
Primary Insurance Company Phone #
__________________________________________ _______________________________________
Policy Holder’s name Relationship to Child
__________________________________________ ______________________________________
ID # Group#
Carefully read the following General Release, Indemnification and Waiver Agreement. It constitutes a legally binding agreement between you and St. John’s.
I. General Release of Liability
I, the parent/guardian of _____________________, freely assume all risks in connection with my child’s participation in St. John’s Parents Day Out program and agree to forever PROTECT, DEFEND, INDEMNIFY AND HOLD HARMLESS St. John’s, its directors, officers, agents and employees from and against any and all claims, damages, suits, cause of action, liabilities and losses, arising out of or connected in any way with the placement of my child in care at St. John’s, including any and all injury, death, damage or loss which the child may sustain or cause, or to which he/she may contribute to any other child enrolled in St. John’s, except cases of gross negligence or willful misconduct by St. John’s or its agents.
II. Medical Release of Liability
In the event of an emergency or non-emergency situation requiring medical treatment. I, ___________________, hereby grant permission for any and all medical and/or dental attention to be administered to my child(ren), in the event of an accidental injury or illness, until such time as parent, guardian or emergency contact can be reached. This permission includes, but is not limited to, the administration of first aid, the use of a thermometer, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel.
III. Still Photos/Video/Audio for St. John’s Use
I hereby grant to St. John’s the right, without fee, to make and use photos and/or video tape recordings of my child in connection with in-house St. John’s Parent’s Day Out activities.
I do not want photos of my child displayed_____ (Initial)
IV. False Information
I understand St. John’s is not responsible for any injury or loss that may arise as a result of false or misleading information given to St. John’s at the time of enrollment.
I UNDERSTAND AND AGREE THAT BY SIGNING THIS AGREEMENT I AM VOLUNTARILY ASSUMING ALL RISKS OF HARM, LOSS, OR INJURY TO MY CHILD TO THE EXTENT DESCRIBED HEREIN. I HAVE FULLY READ AND UNDERSTAND THIS LEGALLY BINDING DOCUMENT.
Signed:
___________________________________________ Date______________________
Parent or Guardian
