* = Required Information



Both Parents Mother Father Other
Both Parents Mother Father Other
The child may be released to the person(s) signing this agreement or to the following:

Person(s) to contact in the case of emergency when parent/guardian cannot be reached:

EMERGENCY MEDICAL AUTHORIZATION
SHOULD (CHILD'S NAME) DATE OF BIRTH SUFFER AN INJURY OR ILLNESS WHILE IN THE CARE OF A STEP ABOVE LEARNING CENTER AND THE FACILITY IS UNABLE TO ME/US IMMEDIATELY, IT SHALL BE AUTHORIZED TO SECURE SUCH MEDICAL ATTENTION AND CARE FOR THE CHILD AS MAY BE NECESSARY. I/WE SHALL ASSUME RESPONSIBILITY FOR PAYMENT OF SERVICES.
PARENTAL AGREEMENTS WITH CHILD CARE FACILITY
A Step Above Learning Center agrees to provide day care for on the days of from to during the months of .
Breakfast
Morning Snack
Lunch
Afternoon Snack
Evening Snack/Dinner
Bedtime Snack
Before any medication is dispensed to my child, I will provide a written authorization, which includes: date, name of child, name of medication, prescription number; if any, dosages, date and time of day medication is to be given. Medicine will be in the original container with my child's name marked on it.

My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by parent(s), or facility personnel.

I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur. i.e. telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans and immunization records, etc.

The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

A Step Above Learning Center agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water - related activities occurring in water that is more than two(2) feet deep.

I authorize the child care facility to obtain emergency medical care for my child when I am not available.

I have received a copy and agree to abide by the policies and procedures for A Step Above Learning Center.

I understand that the center will advise me of my child's progress and issues relating to my child's care as well as my individual practices concerning my child's special needs. I also understand that my participation in encouraged in facility activities.

Parent/Guardian Notice of No Liability Insurance and Acknowledgement
I understand I am being informed in writing by signing this acknowledgement that this child care facility does not carry liability insurance sufficient to protect my child(ren) in the event of an injury, etc.
Per SB24 (2004) requiring child care facility owners who are not covered by liability insurance to provide and retain written notice regarding no coverage to the parents and guardians.
TRANSPORTATION AGREEMENT
  My child also needs to be transported
  My child does not need another ride

  Monday
  Tuesday
  Wednesday
  Thursday
  Friday
is authorized to receive my child. In the event the authorized person is not present to receive my child, the following procedures are to be followed:
The child will return to the center and parent(s)/guardian(s) will be immediately contacted by phone. In the event that the parent/guardian cannot be reached , the authorized pick-up people listed in the enrollment forms will be contacted to pick - up the child. If that is unsuccessful, the emergency contact person will be notified. (If the emergency contact person is not listed as an authorized pick-up person, they are NOT allowed to pick-up the child from the center.) If the child remains on the premises for more than one hour after dismissal, then DFCS will be contacted to pick-up him/her from the center, at the Director's discretion.
This is to certify that I give A Step Above Learning Center permission to transport my child based on the aforementioned terms. In the event that my child is not transported as outlined, I agree to immediately notify A Step Above Learning Center.
VEHICLE EMERGENCY MEDICAL INFORMATION



Person to notify in case of emergency when parents cannot be reached:
In the event of an emergency involving my child, and if A Step Above Learning Center cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all med ical expenses incurred during the treatment and/or ambulance transportation of my child .
MEDICATION AUTHORIZATION
The information provided is true and accurate to the best of my knowledge.
For Center Use Only
DATE TIME GIVEN AMOUNT ANY ADVERSE REACTIONS ADMINISTERED BY
IF NOTICEABLE ADVERSE REACTION TO MEDICATION OCCURS, DESCRIBE WHAT ACTION WAS TAKEN?
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