GENERAL & MEDICAL CONSENT FORM
FOR LITTLE MIRACLES
CHILD CARE CENTRE
I ____________________________ , give permission to _____________________ and/or Staff of Little
Miracles Child Care Centre to take photos of my child: ________________________, during their daily activities in the Centre and on field trips for my own personal photo album and for the use in the Little Miracles Child Care photo album or for the Little Miracles Child Care website, which may be shown to future potential Child Care Clients.
Miracles Child Care Centre to take photos of my child: ________________________, during their daily activities in the Centre and on field trips for my own personal photo album and for the use in the Little Miracles Child Care photo album or for the Little Miracles Child Care website, which may be shown to future potential Child Care Clients.
I _________________________, give permission to ___________________and /or Staff of Little Miracles Child Care Centre to administer over the counter type medication if and when needed when supplied by myself the Parent/Guardian of ____________________, and when on the advice of a Physician.
I also understand that a Doctors note may be requested before any Medication is to be administered to my child and that I may also need to sign a separate Medication Form for Little Miracles Child Care Centre’s Records. I also understand that the Vancouver Island Health Authority (Child Care Licensing), may ask to view these records and any records pertaining to my child at any time as per Child Care Licensing Regulations. (please answer with an initial in the appropriate areas):
Tylenol (when supplied by parent/guardian): Yes_____ No_____
Diaper Cream (when supplied by parent/guardian): Yes_____ No_____
Sunscreen (when supplied by parent/guardian): Yes ______ No _____
Other (when supplied by parent/guardian) Yes_____ No_____
I ___________________________, give permission to the Caregivers of Little Miracles Child Care Centre to give my child an occasional healthy treat:
(please Initial): Yes_____ No_____
I __________________________, give permission to the Caregivers of Little Miracles Child Care Centre to assist my child ____________________ ___with any toilet training procedures (please Initial): Yes______ No_____
I _______________________, give my consent for a Staff member of Little Miracles Child Care Centre to give the necessary First Aid and/or CPR needed to help my child and/or call an Ambulance for my child _________________________ in the case of an Accident or Illness.
_____________________________________ _____________________________
(Parent/Guardian Signature) (Date)
GENERAL FIELD TRIP
CONSENT FORM
The PARENT(S)/GUARDIAN(S) and CAREGIVER(S) agree that the term “Field Trips” shall include spontaneous walks, trips to the beach, parks, playgrounds or others listed below and going to/from David Cameron Elementary School.
The CAREGIVER(S) agree to exercise appropriate levels of supervision, to ensure that adequate safety conditions have been met and to bring along a First Aid Pack on every trip.
The CAREGIVER(S) agree to notify the PARENT(S)/GUARDIAN(S) of field trips requiring special consideration (ie: fees, lunches, clothing, etc.).
The following is a list of the “Field Trips” stated above:
David Cameron School/Playground
Hatley Memorial Park/Pond
Herm Williams Park
Carlow Road Water Park
Veterans Memorial Playground
Saturn Playground (near Belmont School)
JDF Playground/Library
Victoria CCRR Playgroup
West Shore CCRR Playgroup
Esquimalt Lagoon (left side of bathrooms)
The CAREGIVER(S) agree to notify the PARENT(S)/GUARDIAN(S) if and when a new location or activity is to be added to this list.
I ___________________, understand that the Centres owner; _________________and/or Staff, do not claim any liability and/or responsibility for any injuries and/or and damages to the enrolled said child above, and/or to the Parents/Guardians of the said child above, that may or may not be sustained while on or off Child Care Premises, or while in the Child Care Centres Registered Vehicle. The Centre also does not claim any liability and/or responsibility for any damages for lost and/or stolen items.
__________________________ ________________________ ______________
(Parent/Guardian Signature) (Caregiver Signature) (Date)
Doctor’s Wellness Form
Information supplied on this form is for the custody and control of the Care Facility collecting such information as required in the Child Care Licensing Regulations and may be viewed by an employee of the Vancouver Island Health Authority, as it pertains to codes: 403, 500, 601, 605, 802 & 803 of the Community Care Facilities Licensing Health & Safety Book. All information will be kept strictly confidential and only the Parent/Guardian, Caregiver and VIHA will have access to this information.
I ______________________________ state in my opinion that ____________________________ is
(Physician to print name) (child’s name)
well enough to take part in the daily program at Little Miracles Child Care Centre, and is no longer
contagious with ________________________ as of ____________________________________.
(Dr. to write name of illness) (Dr. to write date child is no longer contagious)
I am prescribing the following medication____________________________________ for treatment.
(Physician to fill in if applicable)
I am suggesting parent: (Physician please check all applicable):
- ____ Follow through with another appointment in ________________ days.
- ____ Seek a Specialists Advice
- Other:___________________________________________________________________________
_________________________________________________________________________________.
__________________________ ______________________ __________________
(Physicians Signature) (Physicians ID # &/or stamp) (Date)
