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Heart to Heart Childcare Waiver

Heart to Heart
childcare waiver
- This form is not accepting responses at this time.
  
  Parent must be present on site, but in case of emergency it is necessary that we have general information about your child, as requested below on the waiver.
  
  I request that my child(ren) be accepted in the Heart to Heart childcare program during Heart to Heart. REQUIRED I agree Please fill out this field.
  
  I grant permission for the administration of first aid by the people in charge of the St. Vincent Heart to Heart Childcare (staff and volunteers), as their judgment deems advisable, and for staff to make the necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature. This permission applies to my children listed below on this form. I understand I will be promptly notified in the event of any serious illness or accident and before any major surgery, except when a delay in such communication would endanger life. In the case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the child.
  
  If I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery if deemed necessary for my child. REQUIRED I agree Please fill out this field.
  
  Number of children you are registering for Heart to Heart REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Mother REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's phone number REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact phone number REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Child #1 REQUIRED Please fill out this field. Please enter valid data.
  
  Age of Child #1 REQUIRED Please fill out this field. Please enter valid data.
  
  Allergies/Special Needs/Special Care Instructions for Child #1 REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Child #2 Please enter valid data.
  
  Age of Child #2 Please enter valid data.
  
  Allergies/Special Needs/Special Care Instructions for Child #2 Please enter valid data.
  
  Name of Child #3 Please enter valid data.
  
  Age of Child #3 Please enter valid data.
  
  Allergies/Special Needs/Special Care Instructions for Child #3 Please enter valid data.
  
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