Summer Registration Form 2023

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Email *

Full Name
*

DOB *

YYYY

Allergies or special diet *

Doctor to contact in case of an emergency & Insurance Policy #

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Parent 1

Parent 2

Emergency Contact 1 & Authorization for Pick-up (Full Name, Phone numbers)

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Emergency Contact 2 & Authorization for Pick-up (Full Name, Phone numbers)

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07/17/23 - 07/21/23

FULL DAY

Monday 17

Tuesday 18

Wednesday 19

Thursday 20

Friday 21

Clear selection

07/31/23 - 08/04/23

FULL DAY

Monday 24

Tuesday 25

Wednesday 26

Thursday 27

Friday 28

Clear selection

I would like to sign up for the week of July 31-August 4th
5 mornings

FULL DAY

Monday 31

Tuesday 1

Wednesday 2

Thursday 3

Friday 4

Clear selection

I would like to sign up for the week of August 7th-11th
5 mornings

FULL DAY

Monday 7

Tuesday 8

Wednesday 9

Thursday 10

Friday 11

Clear selection

I would like to sign up for the week of August 14th-18th
5 mornings

FULL DAY

Monday 14

Tuesday 15

Wednesday 16

Thursday 17

Friday 18

Clear selection

Child Permission on/off site activities & field trips:
I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the school, and to leave the school premises under the supervision of a staff member for neighborhood walks or field trips in an authorized vehicle.

I hereby grant permission for the Director or Acting Director to take whatever steps may be necessary to obtain emergency medical care. These steps may include, but are not limited to, the following:

1- Attempt to contact a parent or guardian, the child’s physician, or the persons listed on the emergency information form.
2- If we cannot contact you or your child’s physician we will do one or both of the following: (a) call another physician or paramedics (b) have the child taken to an emergency hospital in the company of a staff member.
3- Any expenses incurred under 2, above, will be the child’s family’s responsibility.
4- The school will not be responsible for anything that may happen as a result of false information given at the time of enrollment.
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I grant permission for On/Off Site Activities & Field trips

PARENTS’ CONSENT FOR EMERGENCY MEDICAL TREATMENT:
As the parent or legal guardian, I hereby give consent to Ecole Claire Fontaine to provide all emergency, dental or medical care prescribed by a dully-licensed physician (M.D) osteopath (D.O.) or dentist (D.D.S) for my child.This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent. This authorization is given pursuant to the provision of Sec. 25.8 of the Civil Code of California and in no event will Ecole Claire Fontaine, its officers, leaders, or agents be held liable for any first aid or surgical treatment or procedures performed pursuant to this consent. If the incident is minor, Arnica Montana 6ch Homeopathic remedy will be administered to accelerate healing and calm inflammation.
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I give Consent for Emergency Medical Treatment

PHOTOGRAPHY, VIDEO, AUDIO RELEASE FORM 2015:
Dear Parents and Guardians:
As you know, when your child takes lessons or participates in events at Ecole Claire Fontaine, it often creates great photo opportunities. We would like your permission to publish these photographs/video/audio recordings on our website, newsletters, social media blogs, yearbooks, etc. to illustrate learning activities in our facility.
We encourage you to follow the links on our website to Facebook, Youtube or our Blog, so you can see how we use these videos/audios and recordings to share and inspire, you can also consult previous yearbooks in our office. All media will be available for parents to review upon request and full names and tags will not be attached. Please review the photograph/video/audio consent options below and choose one box that best represents your request regarding the use of photographs/videos/audio recordings of your child by ECF.
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I GIVE Ecole Claire Fontaine permission to use my child’s image/photograph/video to illustrate educational activities in printed publications, social media or websites. I hereby release and discharge ECF from any claims arising out of the uses of the photographs/videos that my child may appear in.

I hereby give consent to ECF to charge my credit card for any outstanding balances

CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS PARENTS’ RIGHTS
As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office: CA DSS- Licensing Division 300 N. Continental Blvd. Ste 290A (424)301-30777. 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form. NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE. For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents) ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS’ RIGHTS (Parent/Authorized Representative Signature Required) I, the parent/authorized representative of my child, mentioned above, have received a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the reference to the CAREGIVER BACKGROUND CHECK PROCESS form: https://www.cdss.ca.gov/cdssweb/entres/forms/English/LIC995e.pdf
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I hereby read my Rights

A copy of your responses will be emailed to the address you provided.

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