Deming Registration

Does your child attend Deming Early Learning Center?*

yesno

Thank you for your interest in our Before and After School Program, we are required to ONLY register students who are attending Deming Early Learning Center. You may not complete this application.

We need the following care:

Before School (6:30-7:45 a.m.) $25/weekAfter School (2:15-6:00 p.m.) $50/week

We are eligible for a discount because of the following:

1 Child Name:*

1 Sex*

1 Age*

1 Birth Date

Date

2 Child Name:

2 Sex

2 Age

2 Birth Date

Date

3 Child Name:

3 Sex

3 Age

3 Birth Date

Date

1 Parent/Guardian Name:*

1 Parent Phone*

1 Parent Email*

example@example.com

2 Parent/Guardian Name:

2 Parent Phone

2 Parent Email

example@example.com

Home Address:*

CHILD RELEASE INFORMATION: Persons authorized to pick-up child from program

1 Name Authorized:*

Put NA if not applicable

1 Relationship Authorized:*

1 Authorized Phone*

2 Name Authorized:

2 Relationship Authorized:

2 Authorized Phone

3 Name Authorized:

3 Relationship Authorized:

3 Authorized Phone

Persons Unauthorized: Person NOT authorized to pick-up child

1 Name Unauthorized:*

1 Relationship Unauthorized:

1 Unauthorized Phone

2 Name Unauthorized

2 Relationship Unauthorized:

2 Unauthorized Phone

Health Insurance Co:*

Health Insurance Policy Number*

Immunizations up to date*

Doctor's Name:*

Doctor's Phone:*

Dentist Name:*

Dentist Phone:*

List allergies, serious injuries, diseases, operation and any restrictions on physical activity (please include the name of the child it applies to): *

What medications are your child(ren) currently taking?*

List any activities from which the student should be exempted for health reasons:*

Does the child receive special needs services?*

YesNo

Please explain the services the child receives

Does the child require one-on-one services?*

YesNo

Is the child able to use the bathroom without assistance and without diapers?*

YesNo

I, the undersigned parent/person having legal custody/guardianship of the above named minor, give permission for the minor to participate in all THCM programs. The minor is physically able and mentally prepared to participate in all activities as described in the announcement for the program.

In consideration of said minor being permitted to enter Terre Haute Children’s Museum (“THCM”) at Deming Early Learning Center (DELC) for observation, use of facilities and/or equipment, or participation in any program, I, on behalf of myself (as parent, guardian, coach, aide, spectator or participant) hereby:

1. Acknowledge that (i) I have read this document, (ii) I have inspected the THCM facilities and equipment at DELC, (iii) I accept them as being safe and reasonably suited for the purposes intended and (iv) I voluntarily sign this document.

2. Release the THCM, its directors, officers, employees and volunteers (collectively “Releasees”) from all liability to me for any loss or damage to property or injury or death to person, whether caused by Releasees or otherwise and while such minor is in or near THCM at DELC.

3. I agree not to sue Releasees for any loss, damage, injury or death described above and I will indemnify and hold harmless Releasees and each of them from any loss, liability, damage or cost they may incur due to said minor’s presence In, upon or near the THCM at DELC: whether caused by the negligence of Releasees or otherwise.

4. I assume full responsibility for, and risk of, bodily injury, death or property damage due to the negligence of Releasees or otherwise.

5. I do hereby authorize the THCM as agent for the undersigned, to consent with respect to said minor, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by and is to be rendered under general or special supervision of, any physician and surgeon on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the physician oral the hospital. I understand that the THCM is not responsible for costs incurred for medical care.

6. I have read The Terre Haute Children’s Museum’s Program Policies and Procedures. I have discussed this with my child and agree to comply with the discipline policies and procedures.

7. I give the Terre Haute Children’s Museum permission to use any picture or likeness of me, or a picture or likeness of my children, in the THCM’s general publicity and campaign materials. I authorize The Terre Haute Children’s Museum, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I intend this document to be as broad and inclusive as is permitted by the laws of the State of Indiana: if any portion hereof is held invalid, I agree the balance shall continue in full force and effect.

Parent/Guardian Signature*

Print Name*

Date*

Date

Deming Before & After School Care Registration

FAMILY INFORMATION

HEALTH INFORMATION

RELEASE