NACCO Child Drop-Off Application

NACCO Child Drop-Off Application

Please complete this form to apply for enrollment in the NACCO Community Volunteer Child Drop-Off Program. This initiative is designed to provide a safe and supervised environment for children during emergency outings or while their parents are engaged in volunteer activities. Examples of emergency outings include job interviews or other urgent circumstances when no alternative childcare or family support is available. We kindly request that all information provided on the attached registration form be accurate and complete, as this enables us to ensure the safety and well-being of your child. Please be advised that parents or guardians must remain reachable at all times throughout the drop-off period. This service is offered free of charge to our participating volunteers; however, a fee will be applicable to members of the general public. It is important to emphasize that this program is not a licensed daycare center. Nevertheless, children will be cared for by professional Personal Support Workers or volunteers possessing healthcare backgrounds. This program serves as a limited support service intended solely to assist community members in cases of genuine emergencies. No child will be accepted for regular or daily drop-off without a valid and justifiable reason. We sincerely appreciate your cooperation and thank you for supporting NACCO community volunteer activities.

Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address*
example@example.com
Home Address*

Street Address

CityState / ProvincePostal / Zip Code
Home Address*

Street Address

CityState / ProvincePostal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Authorized Persons for Pick-Up (Other than Parent/Guardian)
Does your child have any allergies or medical conditions?*

NoYes (please specify below)
If yes, please list allergies or medical conditions
Additional Comments or Special Instructions
Drop-Off Day
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Health card Number*
Please enter a valid phone number.Format: 0000 000-000-00.
FAMILY DOCTOR OR PEDIATRIC NAME
Date

MonthDayYear
Date
Signature
Please verify that you are human*
My Products
prevnext( X )
NON MEMBERS PER DAY
$50.00 Quantity



NON MEMBERS PER HOUR
$20.00 Quantity



DORMANT VOLUNTEERS PER HOUR
$15.00 Quantity



ACTING VOLUNTEERS
$ Free Quantity



Total

$0.00
Payment Methods

Choose from one of the PayPal options to make your payment.
Should be Empty: