Emergency Contacts: Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.

Allergies, Special Health or Medical Conditions, and Medical Foods

Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed and be kept on file at the program/home.

Please use this section to add those individuals to whom you are giving permission to pick up your child from care. Previously listed Parent/Guardian and Emergency contacts are already authorized.

Permission to photograph/video

Occasionally, Kids Encounter staff takes pictures of the children during normal classroom activities, special occasions, field trips, etc. in order to provide pictured records and memories of these events. In order for a child to have his/her photograph taken, we must have a consent form on file.

By signing this form, I state that I understand and agree that my child (whose name is listed above) may be photographed and/or videoed while under the care of Kids Encounter. I understand and agree that these photos/videos may be used in newsletters and/or the Kids Encounter website/Facebook.

I give my permission for my child to participate in The Kids Encounter Summer Camp at Encounter and to be involved in any and all activities and field trips scheduled and unscheduled. Scheduled and unscheduled field trips will take place away from the church building but always as a group with proper adult supervision. These activities include but are not limited to: movies, water parks, zoos, factories, parks, stadiums, and museums. These activities may require your son/daughter to be transported on Encounter-owned vehicles. Please complete and sign the following form to serve as the permission slip for all activities and transportation.

HOLD HARMLESS AGREEMENT

I understand that participation in the summer camp involves a certain degree of risk. I have carefully considered the risk of involvement and have given consent for my child to participate in all activities. I understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release Encounter, Kids Encounter Summer Camp, the activity coordinators, and all employees, volunteers, related parties, and other organizations associated with the summer camp from any and all claims or liability arising out of this participation.

In case of an emergency involving my child, I understand every effort will be made to contact me. In the event these attempts prove unsuccessful, I hereby give my permission to the medical provider selected by the adult leader in charge to secure, at my expense, proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for the purposes of medical evaluation of the participant, follow up and communication with the participant’s parents or guardian, and/or determination of the participant's ability to continue in the program activities.

By signing this form you assume the entire responsibility and liability for losses, expenses, damages, demands, and claims based on any sustained or alleged to have been sustained by Encounter, its agents, servants, and employees from any and all such losses, expenses, damages, demands and claims.

The agency or daycare listed above receives Federal financial assistance for participating in the Child and Adult Care Food Program (CACFP). Because they receive Federal financial assistance they are required to record and maintain the Ethnic and Racial data of all children enrolled in the CACFP. This information is used solely for the purpose of determining compliance with Civil Right laws and will be kept confidential. We are requesting for each participant to ‘Self Identify’ and provide this information, however it is optional to Self Identify. This ethnic and racial information will remain confidential and on file for 3 years and will only be accessible to authorized personnel.

To Self Identify, please answer the following questions.