Potential After School
Student Information: Date: ______
Child’s Name: ______
Date of Birth: ______
Child’s Address: ______
School Attending: ______Grade______
Guardian Name: ______
Email Address: ______
Primary Days of Care: M T W TH F
Primary Hours of Care: From: a.m.______to: ______
You must send a letter to the school stating PotentialAfter School is picking up your child!
You must notify PotentialAfter School if you will not need me to pick up your child from school!
Family Information:
Mother’s Name: ______
Address: ______
Home Phone: ______
Cell Phone: ______
Employer: ______
Work Phone: ______
Father’s Name: ______
Address: ______
Home Phone: ______
Cell Phone: ______
Employer: ______
Work Phone: ______
Medical Information:
I hereby grant permission for the staff of Potential After School to contact the medical personnel to obtain emergency medical care if warranted.
Doctor/Dentist/Hospital Phone Address
______
Please list any allergies, special medical or dietary needs, or other areas of concern:
______
Contacts:
Your child (ren) will be released only to the custodial parent or legal guardian and the persons listed below. In the event that neither the parent nor legal guardian can be reached, the following people are authorized to be contacted and to remove the child from the facility in case of illness, accident, or emergency.
Name Phone Cell / Home Address
______
Helpful Information about your child:
Please list or describe your child’s special interest, talents or pertinent anecdote(s) you would like to share: ______
Statement of Responsibility:
By submitting this application you are stating that you are legally and financially responsible for the actions of your child (ren). In the event your child is unruly or becomes aggressive towards another child or staff member, the management of POTENTIAL After School reserves the right to remove the child from other children and notify you that the child needs to be picked up from the facility immediately. Failure to comply with said request and / or further like acts by your child can result in PotentialAfter School refusing further childcare services. In the event your child willfully destroys or damages POTENTIAL After School property, POTENTIALAfter School reserves the right to bill you (the parent / guardian) for damages. Failure to provide payment can result in POTENTIALAfter School refusing further childcare services.
Name: ______
Signature: ______
Relationship to Child: ______
Date: ______
Authorization to Administer Prescription and Non Prescription Medication:
I authorize Potential to administer the following medication (if applicable)
Child’s Name: ______
Name of Medication: ______
Amount to be given: ______
Times to be given: ______(parent MUST give first dose)
Duration of date authorization ends: ______
Special instructions for administering: ______
Name: ______
Signature: ______
Relationship to Child: ______
Date: ______
Authorization to Transport
I authorize PotentialAfter School to transport my child (ren) to and from school:
Child’s Name:______
Signature: ______
Relationship to Child: ______Date: ______
Permission to Release Photograph
I hereby consent to the collection and use of my child’s
______photograph to be
Name of child
Taken and used to advertise for PotentialAfter SchoolI acknowledge these may be used on
billboards, newsletters or on our website. I understand no personal information, such as
names, phone numbers or any other personal information will be used in
any publication
______
Signature of person giving consent Date
.
This Child Daycare Contract between ______and
(Parent)
______Potential After School______ is for the enrollment of
(Provider)
______
(Child(ren)
for child care services under the terms and conditions of this agreement.
Above signed Parent agrees to pay (Full time) $______(Part time) $______per week for the care of my child(ren) on the following days:
Mon______Tues______Weds______Thurs______Fri______
Payment for services is to be paid Monday morning prior to care for the upcoming week. A $5.00 day late fee will be charged per day if your payment is not received on time. Mid week enrollment will be pro-rated.Parent understands that payment is a guaranteed rate and includes full pay for holidays, with no credit for absent or sick days. If a holiday falls on a Monday when daycare is closed, payment will be accepted on Tuesday with no late charge. If for any reason your child(ren) will not be attending daycare on Monday, parent is still responsible for payment on the scheduled day unless other arrangements have been made. Payments in advance will be accepted. Daycare observes and is closed for the following holidays:
- New Years Eve Day
- New Years Day
- Good Friday
- Memorial Day
- Independence Day (4th Of July)
- Labor Day
- Thanksgiving (Thursday And Friday)
- Christmas Eve Day
- Christmas Day
Note: If a holiday falls on a Saturday, that holiday will be observed on Friday, if a holiday falls on Sunday, that holiday will be observed on Monday. Example 1: If Christmas Eve Day is on Friday and Christmas Day is on Saturday, Christmas Day will be observed on Thursday. Example 2: If Christmas Eve Day falls On Sunday and Christmas Day falls on Monday, Christmas Eve Day will be observed on Tuesday.
Example 3: If Christmas Eve Day falls on Saturday and Christmas Day falls on Sunday, Christmas Eve Day will be observed on Friday and Christmas Day will be observed on Monday.
Vacations: When child(ren) take(s) a vacation, parent is required to provide a two (2) week notice prior to vacation. Parent is allowed 1 (one) week vacation per year. Parents are allowed an additional vacation during the same year at half rate. Payment is due prior to your vacation. .
Medicine: Provider will administer medicine to your child(ren). Daycare Administer Medicine Form will need to be filled out and signed by the parent. All medicine will be properly stored and the container must be labeled and clearly marked with your child(rens) name(s), the dosage, and times to be administered. Medicine supplied in an unmarked, unlabeled container will not be administered.
Illness: We must maintain a healthy environment for the benefit of your child(ren) and the other children enrolled in daycare. A child must stay home if they have a fever (100 or above), are vomiting, has diarrhea, or any illness which is determined to be harmful to your child(ren) or the children enrolled in daycare. If your child becomes ill while at daycare provider will call parent to come pick up their ill child immediately.
Please notify provider before __8:00_ am if your child will not be attending that day.
A Two (2) week notice must be given by parent to the provider if child(ren) will be leaving daycare.
Parent keep provider updated with any address, employment, phone number, or emergency contact information changes.
Operating Hours: Play Time closes at _6:00_ pm sharp! A late fee of $_1.00_ will be assessed for every minutes that a parent is late picking up their child(ren).
I have read and agree to all the terms and conditions of this agreement.
______Parent Signature: Date
______Potential After School______Day Care Provider Date
PotentialAfter School
Waiver and Release of Liability
Name______
Address______
Phone#1______Phone#2______
Acknowledgement of Risks
In consideration of being allowed to participate or use this facilities and the equipment of PotentialAfter School Center______,
(name of participant
I acknowledges, agreeand appreciate that there are risk associated with bounce houses, trampolines, and other activities at Potential After School. These risk could result in injury, illness, paralysis, or death. Failure of equipment, my own and other’s failure to follow proper procedures, rules and instructions, as well as my own and other’s recklessness. The above list is not complete or exhaustive, and other risks known and unknown may exist.
Release, Indemnification and Covenant Not to Sue
In consideration of being allowed to participate and/or use facilities and equipment of Potential. I on behalf of myself, my heirs, legal representatives and assigns hereby voluntarily release and covenant not to sue Potential center, its officers, agents, employees, owner, successors, and assigns, for the cause of action claim, or demand of any nature whatsoever which relate to or arise out of my use of the facilities, equipment and gear, including but not limited to, inflatables, trampolines, skating at Potential.
Agreement to Follow Rules and Safety Procedures
I accept full responsibility for my safety and the safety of others. I agree to abide by the rules and safety procedures of Potential.
I HAVE CAREFULLY READ THIS FORM AND FULLY UNDERSTAND ITS CONTENTS. I UNDERSTAND THAT I HAVE GIVEN UP LEGAL RIGHTS AND THAT THIS IS A BINDING LEGAL DOCUMENT.
______
Participant SignaturesDate
______
Witness Signatures
Parent or Guardian of Person under the age of 18.I, as parent or guardian of the participant, give my permission for any child or ward to participate and/or use the facility, equipment at Potential After School Center. I agree on behalf of myself and the other parent or guardian of the participant to the terms of this waiver and release of liability. I have fully explained the contents of this form to my child and/or children under my care.
______
Parent or Guardian Signature Date