Release of Child My child will be picked up at the K-Excel Program by me or one of the following individuals (Must be 18 years or older and present valid photo ID): Name
Relationship to Child
Telephone #
Name
Relationship to Child
Telephone #
I give my permission to Mt. Olive Child Care & Learning Center for the following: 1. In conjunction with the Mt. Olive Elementary School Nurse on staff, to provide medical treatment to my child-basic first aid and if necessary, to transport my child to the closest hospital via ambulance for treatment. 2. To authorize the emergency contact people listed in this application (Emergency Medical Care section) to act on my behalf until I am available. 3. For my child to participate in field trips and walks sponsored by the KExcel Program. 4. For my child to be photographed, videotaped, or filmed and use his/her work for display and publication. 5. To release objective information about my child to appropriate personnel employed by the Mt. Olive Township Public Schools (i.e. Child Study Team, Principals, Teachers, etc).
EMERGENCY MEDICAL CARE (To be completed by the parent/guardian) Student’s Name: 1. 2. 3.
Date of Birth:
If my child requires emergency medical care and I cannot be reached, I give my consent to the K-Excel Program, in conjunction with the Mt. Olive Elementary School Nurse, to obtain the necessary medical care for my child. I agree to pay all costs associated with the care that my child receives. I understand that every effort will be made to contact me before medical care is provided. This information is strictly confidential and will not be shared with anyone without my written consent or in the case of emergency medical care. My child may be released to these individuals following medical care (Must be 18 years or older and present valid photo ID): Name: Address: Home #: Cell #: Work #: Relationship to Student: Name: Address: Home #: Cell #: Work #: Relationship to Student: Name: Address: Home #: Cell #: Work #: Relationship to Student:
4.
Health Insurance Information: Student’s Doctor: Doctor’s Address: Phone #: Insurance Carrier: Member/Policy ID #: Religious Preference (optional): Daily Medications Taken:
5.
I understand that this consent will be in effect as of the signature date below and will continue as long as my child is enrolled in the K-Excel Program.
STUDENT HEALTH RECORD (To be completed by the parent/guardian) Student’s Name:
Date of Birth:
Child’s Medical History: (Check all that apply) Prior Illnesses/ Current Conditions Asthma Convulsions/Seizures Diabetes Ear Infections Chicken Pox Measles German Measles Rheumatic Fever Mumps Corrective Device (i.e. glasses, hearing aid, etc.) Inhaler
YES
NO
If you checked YES for any of the above, please specify, provide dates, and instructions:
List significant illnesses or surgeries. Provide dates and any instructions.
Allergies: (Check all that apply) Allergy Penicillin Insect Bites/ Stings Foods Plants Hay Fever Seasonal Allergies Topical Ointments Other
YES
NO
If you checked YES for any of the above, please specify, provide instructions, and describe reaction:
List special situations/needs (i.e. behavioral/emotional difficulties, physical disabilities, etc.) that the program staff should be aware of to best care fro your child.
Special Health Care Needs and/or Medications:
Does your child have special health care needs that require treatment and/or medication? YES ___ NO ___ If YES, please describe below: Does your child take medication for any condition or illness? YES ___ NO ___ If YES, please describe below:
If your child requires treatment and/or medication during the K-Excel Program hours, please be advised that all treatments and/or medications will be administered by the Mt. Olive Elementary School Nurse on staff. Please be sure a Health Care Plan for a Child with Special Health Care Needs form and/or a Medication Consent form is on file with the Mt. Olive Child Care & Learning Center’s K-Excel Staff.
Parent/Guardian Signature ___________________________________ Date
