The Incredible Years | CHILD CARE REGISTRATION FORM

How many Children will you be Registering?(Required)

1st Child's Information

Child's Full Name(Required)

First Last Preferred Name/Nickname

Age(Required)

Please enter a number from 1 to 18.

Date of Birth(Required)

Gender

Does your child have any allergies (food, environmental, medications)?(Required)

Child's Allergy(ies)(Required)

Does your child(ren) have any medical conditions, medications, or special needs we should be aware of?(Required)

Medical Instructions(Required)

Does your child require an EpiPen, inhaler or other emergency medication?(Required)

Is your Child potty-trained?(Required)

Are there any behavioral, developmental, or sensory considerations that our staff should know?(Required)

What helps calm or comfort your child if they come upset?(Required)

2nd Child's Information

Child's Full Name(Required)

First Last Preferred Name/Nickname

Age(Required)

Please enter a number from 1 to 18.

Date of Birth(Required)

Gender

Does your child have any allergies (food, environmental, medications)?(Required)

Does your child(ren) have any medical conditions, medications, or special needs we should be aware of?(Required)

Medical Instructions(Required)

Does your child require an EpiPen, inhaler or other emergency medication?(Required)

Is your Child potty-trained?(Required)

Are there any behavioral, developmental, or sensory considerations that our staff should know?(Required)

What helps calm or comfort your child if they come upset?(Required)

3rd Child's Information

Child's Full Name(Required)

First Last Preferred Name/Nickname

Age(Required)

Please enter a number from 1 to 18.

Date of Birth(Required)

Gender

Does your child have any allergies (food, environmental, medications)?(Required)

Does your child have any medical conditions, medications, or special needs we should be aware of?(Required)

Medical Instructions(Required)

Does your child require an EpiPen, inhaler or other emergency medication?(Required)

Is your Child potty-trained?(Required)

Are there any behavioral, developmental, or sensory considerations that our staff should know?(Required)

What helps calm or comfort your child if they come upset?(Required)

4th Child's Information

Child's Full Name(Required)

First Last Preferred Name/Nickname

Age(Required)

Please enter a number from 1 to 18.

Date of Birth(Required)

Gender

Does your child have any allergies (food, environmental, medications)?(Required)

Does your child have any medical conditions, medications, or special needs we should be aware of?(Required)

Medical Instructions(Required)

Does your child require an EpiPen, inhaler or other emergency medication?(Required)

Is your Child potty-trained?(Required)

Are there any behavioral, developmental, or sensory considerations that our staff should know?(Required)

What helps calm or comfort your child if they come upset?(Required)

5th Child's Information

Child's Full Name(Required)

First Last Preferred Name/Nickname

Age(Required)

Please enter a number from 1 to 18.

Date of Birth(Required)

Gender

Does your child have any allergies (food, environmental, medications)?(Required)

Does your child have any medical conditions, medications, or special needs we should be aware of?(Required)

Medical Instructions(Required)

Does your child require an EpiPen, inhaler or other emergency medication?(Required)

Is your Child potty-trained?(Required)

Are there any behavioral, developmental, or sensory considerations that our staff should know?(Required)

What helps calm or comfort your child if they come upset?(Required)

Parent/Guardian Information

Parent/Guardian Full Name(Required)

First Last

Relationship to Child(ren)(Required)

Phone(Required)

Email(Required)

Emergency Contact

First Last

Phone

Consent(Required)

I agree to the Absolute Release of Liability

ABSOLUTE RELEASE OF LIABILITY I, as parent/guardian of the named participant(s), acknowledge and accept the inherent risk of harm that may arise while engaging in activities offered and sponsored by the Autism Society Northwestern Pennsylvania (the “Society”). By signing this Release of Liability and Acknowledgment of Conduct, I hereby consent to myself, the named participant(s), and other member(s) of my party, to participate in activities offered by the Society. I acknowledge that the activities offered by the Society may include other participants and will occur on and/or with equipment owned and/or operated by the Society. Having acknowledged the inherent risk of harm associated with engaging in the aforementioned activities, I do hereby, for myself, the named participant(s), and other member(s) of my party, waive and release any and all rights and claims for damages that I, the above named participant(s), or other member(s) of my party may have at any time against the Society, or any of its agents for any injury or damages in connection with me or the attendees’ engagement with activities with other individuals or any other activity associated with or sponsored by the Society. I understand, as the parent or guardian of the named participant(s), that I am responsible for all property damage caused by the named participant(s), my attendees, and/or me. I agree to replace, at my own expense, or to reimburse the Society for all losses, breakage or required repairs that were caused by my named participant, my attendees, and/or me. MEDICAL RELEASE: I understand that myself, other parent/guardian of the named participant(s), or our designated agent may be asked to provide authorization for necessary medical care. In the event that the parent/guardian or their agent is not present, I hereby authorize the Society or their designees to authorize treatment for my child for injuries or illnesses that they may incur while participating in any activities offered by the Society. I authorize necessary treatment and admission for any hospitalization designated by the Society, or their designate. ALLERGEN WARNING: I/we acknowledge that all foods and drinks offered by the Society may contain commonly known allergens, such as dairy, eggs, wheat, soybeans, tree nuts, peanuts, fish, shellfish or wheat. I recognize that it is my/our responsibility to inform the Society of any known allergic sensitivities prior to the participant(s) engaging in activities offered by the Society. I recognize that I/we am/are permitted to supply our own food for the names participant(s) in lieu of the food and drinks being offered by the Society. I hereby release the Society of any liability arising out of allergic reactions due to food or drinks consumed in the course of activities offered by the Society. REMOVAL FROM ACTIVITES: I understand that the Society may, in its absolute discretion, remove the named participant(s), myself, and/or other members of my party if any of the aforementioned persons cause intentional damage to the property the Society, exhibit aggressive behavior towards any staff/peers/or self, or place others at risk of harm due to intentional release of bodily fluids.

Signature of Parent/Guardian(Required)

Date

Childcare for The Incredible Years Program

1st Child's Information

2nd Child's Information

3rd Child's Information

4th Child's Information

5th Child's Information

Parent/Guardian Information

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