New Application Emergency Contact FormAgreement FormInitial Page (receive shirt, IEP Letter Permission for Photos, Transfer Letter, Transition Letter)Child Pick-up AuthorizationEmergency Operation Plan LetterHealth AssessmentCovid Initial FormCovid Agreement Parent Signature: Date: Director/ Assistant Signature Date: EMERGENCY CONTACT PARENTAL CONSENT FORM 55 PA CODE CHAPTERS 3270.124(a)(b), 3270.181 & 182, 3280.124(a)(b), 3280.181 & 182, 3290.124(a)(b), 3290.181 & 182 CHILD'S NAME: BIRTH DATE: ADDRESS: MOTHER'S NAME/LEGAL GUARDIAN : HOME TELEPHONE NUMBER: E-MAIL ADDRESS: MOBILE TELEPHONE NUMBER: ADDRESS: BUSINESS NAME: BUSINESS TELEPHONE NUMBER: ADDRESS: FATHER'S NAME/LEGAL GUARDIAN : HOME TELEPHONE NUMBER: E-MAIL ADDRESS: MOBILE TELEPHONE NUMBER: ADDRESS: BUSINESS NAME: BUSINESS TELEPHONE NUMBER: ADDRESS: EMERGENCY CONTACT PERSON'S NAME: TELEPHONE NUMBER WHEN CHILD IS IN CARE: PERSON(S) NAME TO WHOM CHILD MAY BE RELEASED : ADDRESS: TELEPHONE NUMBER WHEN CHILD IS IN CARE: NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER: TELEPHONE NUMBER: ADDRESS: SPECIAL DISABILITIES (IF ANY): ALLERGIES (INCLUDING MEDICATION REACTIONS): MEDICAL OR DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION: MEDICATION. SPECIAL CONDITIONS: ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD: ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD: HEALTH INSURANCE COVERAGE FOR CHILD OR MEDICAL ASSISTANCE BENEFITS: POLICY NUMBER (REQUIRED): PARENTS SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT: OBTAINING EMERGENCY MEDICAL CARE: ADMIN. OF MINOR FIRST - AID PROCEDURES: WALKS AND TRIPS: SWIMMING: TRANSPORTATION BY THE FACILITY: WADING: Agreement Form 55 PA CODE CHAPTERS 3270.123&.18l(C); 3280.123&0l81 (c); 3290.123&.18I (c) Name of Child: BIRTH DATE: $ Per-day-Week: Week Day payment to be Made: Monday Type of Service: InfantYoung ToddlerOlder ToddlerPreK Counts/Headstart ONLY (NoCharges to families in the Program)Before CareAfter CareBefore and After CareSummer Camp Services to be provided as part of the daycare fee (examples; transportation, care, meals, etc.): Breakfast, Lunch, Snack, Child Service Report/ Assessments, Parent Conferences, Themed weekly curriculum, Parent Resources, and School Trips with Transportation for PreK Counts and Head Start Children Child arrival time: Child departure time: Late fee's $10-5:31pm-5:36pm- $1.00 a min-After 5:36pm PKC and HS - $25 at 3:01 pm Person(s) designated by parent to whom child may be released: Extra services to be provided at an additional fee if applicable: I, the parent/guardian; Received complete written program information at the time of enrollment (S 3270.121, 3280.121 ,3290.121) Agree to update the emergency contact/ parental consent for information whenever changes occur or every 6 months at a minimum. (S 3270.124, 3280.124, 3290.124) Signature of Director: Signature of Director: Signature of parent or guardian: Date: Date of child’s Admission: Date of child's Withdrawal: PLEASE PUT YOUR INITIALS NEXT TO WHAT IS APPLICABLE FOR YOUR CHILD Date: Parent Signature:
