child care drop in waiver

Child / Participant Information

information must be complete prior to first visit
Date Form Completed *
Date Form Completed
Child's Name *
Child's Name
Birthdate *
Birthdate

Parent/Guardian Information

Parent/Guardian *
Parent/Guardian
Primary Phone *
Primary Phone
Secondary Phone
Secondary Phone
Address *
Address
Parent/Guardian (2)
Parent/Guardian (2)
Primary Phone
Primary Phone
Address
Address

Emergency Contact

Person(s) Emergency Contact (other than parent/guardian listed above)
Name (1) *
Name (1)
Phone *
Phone
Address *
Address
Name (2)
Name (2)
Phone
Phone

Medical Information

Physician’s Name *
Physician’s Name
Phone *
Phone
Address *
Address

Terms of Agreement

Photography *
Photos may be taken and used to promote Child Care at Germantown Athletic Club. By signing this, you, the parent/guardian, give permission for your child’s picture to be on the Club website, social media and/or other means of marketing such as newspaper advertisements.
Waiver *
In consideration for being allowed to participate and/or enroll my child to participate in the activities relating to the Drop In Child Care, I hereby expressly reassume all risks and hazards, both known and unknown, incidental to my child’s participation in the Drop In Child Care and assume full responsibility for all risks of bodily harm and property damage resulting from or in connection with my child’s participation in the Drop In Child Care, including without limitation.  I hereby voluntarily release, waive and forever discharge and agree to indemnify and hold harmless, the City of Germantown, its elected officials, officers, employees, agents, representatives and related persons (collectively the “Releasees”) and from any and all liabilities, claims, damages, injuries and losses, including attorney’s fees and courts costs, resulting from, arising out of or connected in any way with my child’s participation in the Drop In Child Care and related activities; and further agree to indemnify, defend and hold the Releasees harmless from and against any and all liabilities, claims, damages, injuries and losses, including attorney’s fees and courts costs, for personal injury or property damage to any person or entity resulting from or related to my child’s participation in the Drop In Child Care.
Medical Statement *
I hereby give permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member. In the event I cannot be located and/or contacted, I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical and hospital care treatment and procedures to be performed for my child by a licensed physician or hospital selected by the Germantown Athletic Club Director when deemed immediately necessary or advisable by the physician to safeguard my child’s health.
Curriculum Review *
I have been provided an opportunity to review the agency’s personal safety curriculum, and have been notified of the sexual abuse/personal safety curriculum for their child.
Immunizations *