Authorization Form — Co-op Preschool

Child Information & Authorization Form

CHILD'S INFORMATION

Child's Name

First Name

Last Name

Name Child Goes By

Child's Date of Birth

YYYY

Gender

Boy

Girl

Home Address (Street, City, and Zip Code)

PARENT #1 CONTACT INFORMATION

Parent #1 Name

First Name

Last Name

Parent #1 Cell Phone

(###)

###

####

Parent #1 Email Address

Parent #1 Employer

Parent #1 Employer Address

PARENT #2 CONTACT INFORMATION

Parent #2 Name

First Name

Last Name

Parent #2 Cell Phone

(###)

###

####

Parent #2 Email Address

Parent #2 Employer

Parent #2 Employer Address

ADDITIONAL CONTACT INFORMATION

Are there any special instructions on reaching you during school hours?

(Work, classes you are attending, health club, etc.)

CHILD'S MEDICAL INFORMATION

Child's Doctor

Doctor's Phone Number

(###)

###

####

Doctor's Address

Child's Dentist

Dentist's Phone Number

(###)

###

####

Dentist's Address

Hospital of Choice

(Please select One)

Poudre Valley Hospital (1024 S Lemay Fort Collins, CO 80524 970-495-7000)

Banner Emergency (4700 Lady Moon Drive Fort Collins, CO 80528 970-421-4000)

UC Health Emergency (4630 Snow Mesa Drive Fort Collins, CO 80528 970-237-8100)

Medical Center of the Rockier (2500 Rock Mountain Loveland, CO 80538 970-624-2500)

Special Needs

(Allergies, Chronic Conditions, Physical Limitations, Medications, etc.)

PICK UP AUTHORIZATION

The following persons are authorized to pick up my child from preschool.

Pick Up Person #1

First Name

Last Name

Pick Up Person #1 Phone Number

(###)

###

####

Pick Up Person #1 Address

Pick Up Person #2

First Name

Last Name

Pick Up Person #2 Phone Number

(###)

###

####

Pick Up Person #2 Address

Pick Up Person #3

First Name

Last Name

Pick Up Person #3 Phone Number

(###)

###

####

Pick Up Person #3 Address

EMERGENCY CONTACTS

The following persons are authorized to assume responsibility for my child in the event of an emergency if parents cannot be reach immediately.

Emergency Contact #1

First Name

Last Name

Emergency Contact #1 Phone Number

(###)

###

####

Emergency Contact #1 Address

Emergency Contact #2

First Name

Last Name

Emergency Contact #2 Phone Number

(###)

###

####

Emergency Contact #2 Address

Emergency Contact #3

First Name

Last Name

Emergency Contact #3 Phone Number

(###)

###

####

Emergency Contact #3 Address

PLEASE AUTHORIZE THE FOLLOWING WITH YOUR INITIALS

Emergency Care Authorization

In the event of an illness or injury which requires immediate medical treatment at a time when a parent cannot be reached, I give permission for the personnel of FUMC Co-op Preschool to authorize such treatment. I will not hold the preschool, its personnel, First United Methodist Church, or medical personnel responsible. I will accept the expense of this emergency care. This is done with the understanding that every attempt will first have been made to contact the parents, the child's Doctor, and other persons listed for emergency contacts.

Sunsceen Acknowledgement

The Colorado Department of Human Services requires that sunscreen be applied daily prior to going outside. Please apply sunscreen to your child at home using a minimum of SPF 15 or before leaving your child at school for the morning with school supplied sunscreen Rocky Mountain Sunscreen for Kids. Please read this information and fill out the form below to acknowledge and agree to follow these state guidelines. • Sunscreen should be applied to exposed skin, including face, tops of ears and bare shoulders, arms, legs and feet. • I understand that it is my responsibility to check the ingredients of Rocky Mountain Sunscreen to ensure my child is not allergic to it. • When signing my child in I agree to confirm daily that sunscreen has been applied for the morning by checking sunscreen applied on the sign in sheet. • If I neglect to apply sunscreen, I give my permission to FUMC Co-op Preschool to apply sunscreen to my child. Sunscreen will not be applied to any broken skin or if a skin reaction is observed. • Any reactions observed by staff will be reported to the parent.

Covid-19 Waiver Release

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. First United Methodist Co-op Preschool (“FUMCP”) has put in place preventative measures to reduce the spread of COVID-19; however, FUMCP cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending FUMCP could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending FUMCP and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at FUMCP may result from the actions, omissions, or negligence of myself and others, including, but not limited to, FUMCP employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at FUMCP or participation in programming (“Claims”). On my behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless FUMCP, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of FUMCP, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any FUMCP program. BY REGISTERING AND PAYING FOR ANY CLASS OR OTHER ACTIVITY WITH FUMCP, YOU ARE AGREEING TO ALL OF THE ABOVE CONDITIONS AND WAIVERS. PLEASE DO NOT HAVE YOUR CHILD/YOURSELF PARTICIPATE IN ANY CLASS OR EVENT UNLESS YOU ACCEPT AND AGREE TO ALL OF THE TERMS IN THIS AGREEMENT.

Field Trip Authorization

I give permission for my child to accompany his/her class and staff personnel on field trips planned and authorized by FUMC Co-op Preschool These may be neighborhood walks or trips in a vehicle. I understand I must provide my child with adequate car seat protection if a vehicle is used. Parents who choose to drive on field trips must provide the Preschool office with a photocopy of their driver's license and proof of current car insurance.

Publications

I understand that my name, email and phone number will be printed in a school directory made available to current preschool families. I understand my email address will be used for classroom and administrative communications. I understand that my address will be printed for the school carpool map. I also give permission for my child to be included in evaluations and pictures connected with the preschool program.

Social Media

FUMC Preschool does not post photos of children taken at preschool on social media. I agree not to post any photos of children taken at preschool on social media other than that of my own child.

ELECTRONIC SIGNATURE CONSENT

By checking here, you are consenting to use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. After consent, you may request a digital or paper copy of this waiver for you records. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent.

Please Add Your Electronic Signature Here