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Date:______________________ Program:_____________________________________ Parent/Guardian:_____________________________ Child:_________________________________ Address:_________________________________City, State, Zip __________________________ Child’s Age:___________ Gender:___ M_____ F__ DOB:_____________________ Primary Physician:______________________________ Phone Number:_________________ Dentist:_________________________________________ Phone Number:_________________ Insurance Company and Policy Number:___________________________________________________ Emergency Contact:_______________________ Relationship______________ Phone Number:____________________ Emergency Contact:_______________________ Relationship______________ Phone Number:____________________ Allergies:________________________________________ Disabilities:_____________________________________________
I give Missouri Shores Domestic Violence Center permission to provide and obtain care for my child. I allow Missouri Shores Domestic Violence Center or a designee to provide transportation as needed for my child. I understand that photos may be taken and I give Missouri Shores Domestic Violence Center permission to display any pictures of my child. I understand that Missouri Shores will not use my child’s last name with any of the pictures they may choose to display. I understand that I am responsible for my child’s transportation to and from MSDVC to participate and will not be more than 15 minutes late for dropping off or picking up my child. If over 15 minutes late to drop off the child, please contact staff to see where the group is. Each day the children will be touring a different location. If the child is not picked up within 30 minutes of the scheduled end time, Missouri Shores DVC reserves the right to notify the Department of Social Services. Because Missouri Shores Domestic Violence Center and employees are identified as helping professionals, all employees are mandated reporters. Therefore, if an employee knows or has reason to believe that a child has been or is being physically abused, sexually abused, or neglected, I understand that this information must be reported to Child Protection Services.
Signature of Parent / Guardian:________________________________________Date:_______________________
MSDVC Staff:______________________________________________Date:_______________________
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