Medical Permission Form

Please note: In order to safely care for your child during Summer at St. Pat’s, we need a medical permission form completed. We will not have a nurse on staff during the Summer Program. If your child is sick or injured, you will be called to pick them up ASAP. All children must be potty trained. For occasional accidents, parents will be called to come and change the child if they are unable to do so themselves. If accidents are habitual, St. Patrick School reserves the right to dismiss the student from the program.

Participant Name

First Name

Last Name

Please check the following:

Check all that apply.

I give permission for staff to apply sunblock to my child as needed and have provided sunblock labeled with my child's name.

I give permission for staff members to obtain emergency medical treatment for my child in my absence.

Health Insurance Company

Health Insurance Policy Number

I acknowledge that pick up for the half-day program is at 11:30am to avoid late fees. After every 15 minutes, an extra charge of $20 will be billed to your FACTS account. Children enrolled in the full day program can be picked up at any point during the day but should be picked up by 3:00pm to avoid late fees. I acknowledge that there is an extra charge of $20 for every 15 minutes late and will be billed to my FACTS account.

I acknowledge the information above.

I acknowledge there is a $50 non-refundable registration fee for each child.

I acknowledge the information above.

I acknowledge that all weekly fees are non-refundable.

I acknowledge the information above.

Name

First Name

Last Name

Date

MM

DD

YYYY