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
School Address
School Address

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.
Observation *
I hereby give permission for my child to be in the facility when observations of children are being conducted by non-child care agency staff.
Immunizations *

Tennessee Department of Human Services Personal Safety Curriculum Notification for Drop In Child Care

Since 1985, Tennessee law has required that children in child care agencies receive annual instruction in personal safety, including child sexual abuse prevention. The personal safety curriculum shall include a Department-recognized component on the prevention of child abuse. Public Chapter 1032 passed by the General Assembly in 2008 require that child care agencies have a personal safety curriculum, including a child sexual abuse component, for children enrolled in the agency, and that parents/legal guardians be informed about the curriculum, methods, and terminology that will be used in teaching children about personal safety. The Department of Human Services was directed to provide guidelines for this curriculum, but individual child care agencies may choose a curriculum that accomplishes the same goal and may use different terminology in the curriculum. The child care agency is required to allow parents/legal guardians to review and ask questions about the curriculum and to meet with the representatives of the child care agency if they have questions. In addition, the child care agency must obtain from parents/legal guardians a form acknowledging that they have been notified of the child sexual abuse/personal safety curriculum being used by the child care agency in which the child is enrolled. A copy of the form is required to be maintained in the child’s record. Because of the nature of Drop-In Child Care Centers, presenting a single, comprehensive curriculum to children of varying ages is not practical. Children would be briefly exposed to random selections from the curriculum from the curriculum out of context and the results would not be beneficial. “Personal Safety Tips for Children and Their Parents” is the sample personal safety tip sheet offered by the Department. This tip sheet is given to parents and provides an overview to aid parents in empowering their children to prevent abuse. This information is not presented directly to the children by this agency. “Personal Safety Tips for Children and Their Parents” is the personal safety curriculum used by our child care agency. The materials used in the agency personal safety curriculum are made available to the parents or legal guardians for use with their children. I/We acknowledge that we 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 our child/children.
My child receives annual personal safety instruction through another educational setting. *
(child's school)
*
Signature of Parent(s)/Guardian(s) *
Signature of Parent(s)/Guardian(s)
Date *
Date