NOTE: Prescription medications will require separate authorizations for each occurrence

and must be sent to school in original prescription bottle.

I authorize The Life Church Child Development Center to obtain the following services

for this child if necessary: Public Health Nurse, Physician, Emergency Room, EMS and/or

Ambulance transport in the event of

an emergency. (Ambulance fees and/or health care costs are the responsibility of the

Please be informed that water play/swimming is a high-risk activity and thus permission

is required for children to participate in these activities. We participate in many water

activities throughout the year which includes but is not limited to water table, water

balloons/guns, sprinkler, wading pool, and swimming pool. Many precautions are being

taken at our facility to help keep children safe when participating in water play,

including but not limited to: Staff trained in an approved water safety course is present

during water swimming activities, children learn water safety rules, and an emergency

plan is in place for pool related activities.

Photographs and videos are taken during on separate occasions such as birthdays, holidays, outings, special occasions as well as in the normal course of our day. We use these pictures/videos for teaching, sharing information about their day, arts & crafts, albums, class books, picture CD’s and various other things. Photos which may include my child may be given to families who also attend this program or may appear in the newspaper unless otherwise

Please mark the appropriate box(s):