Child’s Name: ______________________________
2017 Gateway 2 Hope After School Program Registration Checklist
o
Registration Form (half sheet)
o
Emergency Medical Form
o
Dismissal Form
o
Computer Use Agreement & Photo Release Form (2-sided sheet)
- A registration packet must be completed for each child who attends. CONTACT US: Anita Morrison, Site Coordinator, (
[email protected]) Myrna Craig, AFH Community Outreach Director, (
[email protected])
Alliance for Family Hope Educate. Encourage. Enrich. 5050 Stanley Ave. Maple Heights, OH 44137 (216) 581-9449 E-mail:
[email protected] Website: www.alliancefamilyhope.org
Child’s Name: ______________________________
EMERGENCY MEDICAL AUTHORIZATION FORM Alliance for Family Hope
Child’s Name: ______________________________
Gateway 2 Hope After School Program Date of Birth: ______________ PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured under Gateway 2 Hope After School Program’s authority, when parents or guardians cannot be reached. Information provided on this form will be shared with the program’s personnel who interact with your child to ensure his/her safety at camp unless you note otherwise.
Legal Parent/Guardian (with whom the child lives with) Mother’s Name _______________________________________ Phone: (
) ________-____________
Father’s Name _______________________________________ Phone: (
) ________-____________
Guardian’s Name _______________________________________ Phone: (
) ________-____________
Name of Relative or Childcare Provider: ______________________________ Phone: (
) ________-____________
Address: _____________________________________________________ Street Address Apartment/Unit #
PART I OR II MUST BE COMPLETED PART I - TO GRANT CONSENT I hereby give consent for the following medical care providers and local hospital to be called.
Doctor ____________________________ Phone: (
) ______-_________
Dentist ____________________________ Phone: (
) ______-_________
Preferred Local Hospital ____________________________ Phone: (
) ______-_________
Health Insurance Company _____________________________________ Policy Number _________________________ In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctor, or, in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. I also accept responsibility for any necessary expense incurred in the medical treatment of my child, which is not covered by the insurance company listed above. Please list any facts concerning the child’s medical history including allergies, medications being taken, current medical conditions, and any physical impairments to which G2HASP and a physician should be alerted.
_________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________ Date
_______________________________________ Signature of Parent/Guardian
PART II- REFUSAL TO CONSENT I do not give consent for emergency medical treatment of my child. In the event of illness or injury requiring emergenc
