I give permission for my child First and Last Name* to participate in food-related activities.
Street Address (number, apartment #, street)
Please use additional sheet of paper to list name, address and phone number of any other people authorized to pick the child up.
My signature below verifies that:
I give permission to consult the child's physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached.
I have received a copy of the "Know Your Child's Children's Center" brochure.
I was notified in writing of the disciplinary and expulsion policies used by the children's center.
I was provided the food and nutrition policies used by the children's center.
Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate. I hereby grant permission for the staff of this facility to have access to my child's records.
What is the influenza (flu) virus?
Influenza ("the flu") is caused by a virus which infects the nose, throat, and lungs. According to the US Center for Disease Control and Prevention (CDC), the flu is more dangerous than the common cold for children. Unlike the common cold, the flu can cause severe illness and life-threatening complications in many people. Children under 5 who have the flu commonly need medical care. Severe flu complications are most common in children younger than 2 years old. Flu season can begin as early as October and last as May.
How can I tell if my child has a cold, or the flu?
Most people with the flu feel tired and have fever, headache, dry cough, sore throat, runny or stuffy nose and sore muscles. Some people, especially children may also have stomach problems and diarrhea. Becasue the flu and colds have similar symptoms, it can be difficult to tell the difference between them based on symptoms alone. In general, the flu is worse than the common cold, and symptoms such as fever, body aches, extreme tiredness, and dry cough are more common and intense. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations.
What should I do if my child gets sick?
Consult your doctor and make sure your child gets plenty of rest and drinks a lot of fluids. Never give aspirin or medicine that has aspirin in it to children or teenagers who may have the flu.
CALL OR TAKE YOUR CHILD TO A DOCTOR RIGHT AWAY IF YOUR CHILD:
How can I protect my child from the flu?
A flu vaccine is the best way to protect against the flu. Because the flu virus changes year to year, annual vaccination against the flu is recommended. The CDC recommends that all children from ages up to 6 months up to their 19th birthday receive a flu vaccine every fall or winter (children receiving a vaccine for the first time require two doses). You can also protect your child by receiving a flu vaccine yourself.
What can I do to prevent the spread of germs?
The main way that the flu spreads is in respiratory droplets from coughing and sneezing. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and infect someone nearby. Though much less frequent, the flu may also spread through indirect contact with contaminated hands and articles soiled with nose and throat secretions. To prevent the spread of germs:
When should my child stay home from child care?
A person may be contagious and able to spread the virus from 1 day before showing symptoms to up to 5 days after getting sick. The time frame could be longer in children and in people who don't fight disease well (people with weakened immune systems). When sick, your child should stay at home to rest and to avoid giving the flu to other children and should not return to child care or other group setting until his or her temperature has been normal and has been sign and symptom-free for a period of 24 hours.
My signature below verifies receipt of the brochure on Influenza Virus, The Flu, A Guide to Parents:
A change in daily routine, lack of sleep, stress, fatigue, cell phone use, and simple distractions are some things parents experience and can be contributing factors as to why children have been left unknowingly in vehicles...
Facts About Heatstroke:
It only takes a car 10 minutes to heat up 20 degrees and become deadly.
Even with a window cracked, the temperature inside a vehicle can cause heatstroke.
The body temperature of a child increases 3 to 5 times faster than an adult's body.
During the 2018 legislative session, a new law was passed that requires child care facilities, family day care homes and large family child care homes to provide parents, during the months of April and September each year, with information regarding the potential for distracted adults to fail to drop off a child at the facility/home and instead leave them in the adult's vehicle upon arrival at the adult's destination.
My signature below verifies receipt of the Distracted Adult Brochure.
I acknowledge that on or about March 11, 2020, Coronavirus Disease 2019 (“COVID-19”) was declared a pandemic by the World Health Organization. The Centers for Disease Control and Prevention (“CDC”) has stated that “the best way to prevent illness is to avoid being exposed to this virus.” https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html.
I am aware of the contagious nature of COVID-19 and have voluntarily chosen to allow my child(ren) to participate in programs operated by Pinellas Sheriff’s Police Athletic League, Inc. (“Pinellas PAL
I acknowledge that Pinellas PAL employees come into contact with multiple individuals and might become exposed to COVID-19. I also acknowledge that although Pinellas PAL takes precautions to reduce the likelihood of transmission of COVID-19 by its employees, it cannot guarantee that my child(ren) will not become infected with COVID-19.
I knowingly acknowledge that by allowing my child(ren) to participate in Pinellas PAL’s programs. I am exposing my child(ren) and myself to the risk of becoming infected with COVID-19, which may result in serious personal injury, illness, permanent disability, and death. I understand the risk of becoming exposed to or infected by COVID-19 may result from actions, negligence, and failures to act of myself and others, including, but not limited to, Pinellas PAL employees, and other program participants and parents.
I agree to assume all of the foregoing risks, and accept personal 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 or nature, that I may suffer arising out of or in connection with my child(ren) or myself becoming exposed to or infected by COVID-19 while my child(ren) is/are participating in any Pinellas PAL program. On my own behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, and forever discharge Pinellas PAL, its employees, agents, and representative, of and from all liabilities, claims, actions, damages, costs or expenses of any nature (“Claims”) arising out of or in any way connected with my child(ren) or myself becoming exposed to or infected by COVID-19. I understand that this release includes any Claims based on the negligence, action, or inaction of any of Pinellas PAL, its employees, agents, and representatives, and covers bodily injury (including death) due to COVID-19, whether a COVID-19 infection occurs before, during or after participation in any Pinellas PAL program.
I, First and Last Name* , parent/guardian of blank* ALLOW her/him to walk home alone at the end of the program day. I understand that if I need my child earlier than the end of day, I will contact the office to request her/his early dismissal.
I, First and Last Name* , parent/guardian of blank* DO NOT ALLOW her/him to walk home alone at the end of the program day. I understand that I must pick up my child and/or arrange someone from the escort list below to pick my child up by the end of the program day.
Sibling/housemate in program:Name: First Name* Last Name* Relationship: blank* Age: *
As the parent of First Name* Last Name* , I authorize the emergency release and/or pickup of my child by the following adults, over the age of 18, listed below. I understand appropriate ID will be required for each person that picks up my child. Furthermore, I authorize Pinellas PAL to contact these individuals in case of an emergency when I, or another parent or guardian, cannot be reached.
Beginning August 24th, 2020, PAL is instituting the following rules during transportation from schools to PAL facilities. This is for the health and safety of all staff and participants. It is the student’s responsibility to get to the van on time. PAL is unable to return to pick up students who are late for pickup given the added COVID-19 requirements.
PAL will continue to implement the safety standards already in place:
By signing below, you acknowledge that you have read and agree to comply with this transportation protocol.
I, First and Last Name* (print participant name(s)) acknowledge that I am a participant of Pinellas Sheriff's PAL. I acknowledge that the Juvenile Welfare Board of Pinellas County (“JWB”) provides funds to make the program or service in which I am participating available. I also acknowledge that in order to make sure that all services delivered to participants are of the highest possible quality, JWB may need to review information about me and these services. By signing this Authorization, I am indicating that I understand and agree that my confidential information may be contained in a JWB data collection system and that this data collection system is exempt from disclosure under the Florida Public Records Act. This means that by law, JWB cannot release individually identifiable information about me or the services I receive (Fla. Stat. §119.071 I acknowledge that as necessary to carry out the purposes listed herein, JWB may review all information about me, including my participant file and all other information pertaining to me held by the agency providing the program or service, regardless of whether that information is entered into a JWB data collection system. I further acknowledge that JWB is simply storing and reviewing records and information as the payor for these services, and that JWB generally provides no direct services to me, except in certain circumstances may facilitate service delivery I further acknowledge that JWB does not provide medical diagnoses to me and JWB is not a covered entity as that term is defined under HIPAA (the Health Insurance Portability and Accountability Act).I authorize JWB to utilize my confidential information to verify eligibility for funded services or programs, to facilitate service delivery, make payment for services rendered to me by funded programs or services, quality control of funded services or programs, evidence-based research of JWB funded services or programs, including, but not limited to, tracking outcomes of funded programs and services, and determination of future services/programs funded by JWB. I understand that the confidential information disclosed, received or used by JWB related to my Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law unless it is presented in a report that presents information on a group of individuals in de-identified format, which means that no information that identifies me as an individual is revealed. I acknowledge that this Authorization covers all information about me including, but not limited to, personally identifiable information, Protected Health Information, general medical, general counseling, as well as psychiatric/ psychological/ substance abuse information from my medical health record, any information concerning the performance of any tests, results of those tests, and counseling and treatment records, as allowed by all state, federal and local laws, including, but not limited to the following: Florida Statutes 394.459, 381.004, and 395.3025; Florida Evidence Code 90.503, 90.5035, and 90.5036; HIPAA, and the Code of Federal Regulations (CFR) Title 42. I consent to my minor participating in online or paper surveys that will be used for program improvements and enhancements. I understand that my records have a privileged and confidential status. I am waiving that status for the purposes contained by this Authorization.I understand that the confidential information disclosed, received or used by JWB based on this Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law. However, the individually identifiable confidential information received by JWB based on this Authorization may be used by JWB and its agents for research purposes, so long as the research results are reported as a whole in de-identified format, which means that no information that identifies me as an individual is revealed. Except, JWB will not provide any records covered by CFR Title 42 to any JWB agents. I understand that I have the right to withdraw my approval in writing at any time. However, it is possible that JWB may have already relied on this Authorization before it receives notice of my withdrawal and that JWB may have already taken action based on the Authorization. If I do not withdraw my approval, it will automatically end one (1) year from the last day I received services from this program, or with respect to information used in research, or for compliance and quality review activities performed by JWB or its agents, upon completion of the last research project or compliance/ quality review, whatever occurs latest. By my signature below, I acknowledge that I have given my consent as indicated above freely, voluntarily, and without coercion, and that I have been given a copy of this authorization, signed by me on the date shown below.
By attending Pinellas PAL as a participant, you agree to:
PAL also has extra requirements due to the COVID-19 pandemic, as set in place by the Center for Disease Control (CDC According to these guidelines, you also agree to:
By enrolling your child(ren) at Pinellas PAL, you agree to comply with all PAL expectations and requirements of participation. Specifically, you agree to:
This school year, PAL has certain rules in place based on the Center for Disease Control (CDC) guidelines to help slow the spread of COVID-19. By enrolling your child at PAL, you agree to abide by these guidelines for the safety of our staff, participants, and yourself. Specifically, you agree to:
* Please save the following phone numbers to your list of contacts: