I hereby give permission for Active Minds Academy Staff to provide simple first aid treatment to my child, when necessary. In the event of a more serious illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to receive emergency medical treatment. I also authorize ambulance/EMT to administer such treatment as is medically necessary and authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted. I understand that I will be contacted by childcare program personnel as soon as possible regarding any emergency involving my child.

EMERGENCY CONTACTS & AUTHORIZED PICK UPS

Please list at least two people other than Parent/Guardians that we would be able to contact if are unable to get ahold of the Parent/Guardian in case of illness or emergency. If a person picking up your child is NOT listed on this form, you must notify the Director by verbal or written consent. Photo ID WILL be required of any person picking up your child.

Person(s) NOT authorized to pick up child:

I (we) hereby authorize Active Minds Academy to initiate debit entries to my (our) checking, credit or debit accounts as indicated below. This authority will remain in effect until last payment needed for care upon giving notice, written agreement for new payment arrangements are made with a director or termination of services. Payments are withdrawn in accordance with the agreed upon payment plan. Please reference the Billing Calendar to ensure that you are choosing the best option for family.

*Credit and Debit cards are accepted but a 3% fee is added weekly for processing. There is no processing fee for paying through ACH.