EarlyON | Waterloo Region Parent and Legal Guardian Attestation- 2023

The Ministry of Education continues to recommend that all adults and children complete and pass the Ministry of Education Covid-19 screening prior to attending any in-person programs and services. In the case where a parent/legal guardian is not accompanying their child to the EarlyON location, the parent/legal guardian must complete a Parent Attestation. The form must be received, completed in full and terms agreed to prior to your child attending any EarlyON Child and Family Centre in-person indoor or outdoor program with a caregiver in Waterloo Region. Once received, the parent attestation will remain in effect until further notice. Please follow us online @ EarlyONWR, subscribe to our newsletter, read the EarlyON Experience page, and/or call us at 519-741-8585 ext. 3001 prior to each visit to confirm parent attestation guidelines/timelines.

A family can bring a physical copy of the attestation with them to the EarlyON program or service. If bringing in a paper copy, it is recommended the caring adult keep possession of the original paper copy to allow them to show the copy to each EarlyON location they attend while the attestation is in effect. A caring adult must be a minimum age of 16 years to accompany a child to an EarlyON program.

PLEASE READ THE TERMS IN SECTION B CAREFULLY, AS THEY AFFECT YOUR LEGAL RIGHTS. EarlyON Child and Family Centres in Waterloo Region are managed by the YMCA Three Rivers (Midwestern Ontario) as the Lead Agency, with The Regional Municipality of Waterloo, Children’s Services providing oversight and funding to the system.

1. Parent/Legal Guardian Name*

First Name Last Name

2. Parent/Legal Guardian Phone Number*

Area Code Phone Number

3. Parent/Legal Guardian Email Address - Your email address will be used to email you a copy of this form for your records.*

example@example.com

4. Please list the name of all child(ren) you are providing permission for (Please ensure names listed below match the names of the children as entered into KEyON):

Child 1*

First Name Last Name

Child 2

First Name Last Name

Child 3

First Name Last Name

5. I am the parent or legal guardian of all children listed in question 4?*

YesNo

If you answered "no" to the above question, you cannot sign this form. You must be a parent or legal guardian of the children listed in question 4 above.

6. I agree to complete the Ministry of Education COVID-19 screening for each child prior to a visit to an in-person EarlyON indoor or outdoor program or service.

Your answer is:*

YesNo

7. I agree that if my child has any symptoms of COVID-19 or other contagious illness or my child fails the COVID-19 screening on the day of their visit, they will not attend the in-person EarlyON indoor or outdoor program or service.*

YesNo

8. I understand that if my child has physical symptoms of COVID-19 or other contagious illnesses at the time of their visit, the EarlyON Child and Family Centre staff may refuse the child entry or may ask that child leave the EarlyON program or service and only return after being 24 hour symptom free of any symptoms of contagious illness or 48-hours symptom free of gastrointestinal symptoms.*

YesNo

9. The adult listed below will be bringing my child(ren) to an EarlyON indoor or outdoor programming venue (please submit a new attestation for each new caring adult visiting the centre with your children. Please ensure the name listed below matches the name of the caregiver as entered into their KEyON account) *

First Name Last Name

10. Phone Number of the Adult Attending:*

Area Code Phone Number

11. I understand this attestation will remain in effect in 2023 until further notice. I understand that it is my responsibility as the child’s parent to resubmit further parent attestation as needed if/when guidelines shift.*

YesNo

12. I understand that should I want to cancel this parent attestation, it is my responsibility to contact EarlyON Waterloo Region in writing at earlyyearsinfo@ytr.ymca.ca.*

YesNo

B. Consent and Release

I agree that by signing below (whether electronically or in hard form), I create a binding legal agreement (the “Agreement”) with The Regional Municipality of Waterloo (the “Region”), YMCA Three Rivers (Midwestern Ontario ) (“Three Rivers”) and any EarlyON Service Provider within Waterloo Region, governing your children(s) listed in item 3 above (the “Children”) use of the EarlyON Services in Waterloo Region.

COVID-19 Release

EarlyON Child and Family Centres in Waterloo Region (a “Centre”) are following the guidance provided by the Province of Ontario through the Ministry of Education and local Public Health to protect the health of all participants during the COVID-19 pandemic. However, despite these enhanced safety measures there is still the possibility that you or your Children may get COVID-19. By signing this form you forever release the Region, YMCA of Three Rivers and any EarlyON Child and Family Centre Provider in Waterloo Region from any and all liability for any and all claims, demands, actions, damages (including direct, indirect, special and/or consequential), losses, actions, judgments, and costs (including legal fees) (collectively, the “Claims”) which you or your Children may have or may in the future have, that might arise out of, result from, or relate to you, members of your household or your Children being exposed to COVID-19 or you exposing any member, other guest of the Centre to COVID-19 as a result of your Children(s) use of the services at a Centre.

In consideration of myself and/or my Children participating in the services at a Centre, by signing below (whether electronically or in hard form), I, being the parent or legal guardian of the Children hereby provide my consent for my Children to participate in in-person programming at the Centre and agree to the above terms and conditions.

Name*

First Name Last Name

Date*

Date

Signature (Note: where children are listed on the form, the signature must be of their Parent or legal guardian*

Note: where children are listed on the form, the signature MUST be of their parenting or legal guardian. Clear

Notice of Collection: The information collected on this form is at the direction of the Province of Ontario, through the Ministry of Education (Rules for child care and early years programs) and the Region of Waterloo Public Health (Waterloo Region Child care centres and early years’ settings guidance). The purpose of the collection is to help ensure the health and safety of the participants and staff attending EarlyON Child and Family Centre programs in Waterloo Region, and to support contact tracing by Region of Waterloo Public Health during the COVID-19 pandemic, should that be necessary.

Should you have any questions about the collection of information please contact the Region of Waterloo, Manager, Partnerships, Quality and Accountability at 519-575-4400, ext. 5429 or at ksanguesa@regionofwaterloo.ca.

Regional Municipality of Waterloo Attestation and Parent or Legal Guardian Permission Form