NATURE BABIES "*" indicates required fields Step 1 of 6 16% Child's Name* First Last Child's Birth Date* MM slash DD slash YYYY #1 Parent/Guardian Name* First Last #1 Parent/ Guardian Email* #1 Parent/Guardian Cell Phone*Please select the session(s) you will be joining us for Nature BabiesNature Babies meets every Wednesday 9:30 AM – 11 AM Oct. – Jun. Please select all the months you will be joining us. October Session 10/4, 10/11, 10/18, 10/25 November Session 1/1, 11/8, 11/15, 11/29 December Session 2/6, 12/13, 12/20, 1/3 January Session 1/10, 1/17, 1/24, 1/31 February Session 2/7, 2/14, 2/21, 2/28 March Session 3/6, 3/13, 3/20, 3/27 April Session 4/3, 4/10, 4/17, 4/24 May Session 5/1, 5/8, 5/15, 5/22 June Session 5/29, 6/5, 6/12, 6/19 Child Identifying InformationRequired by the Early Education and Care (EEC) Regulations:Child's Eye Color* Childs Hair Color* Childs Skin Color* Height* Weight* Sex* Identifying Marks (if not applicable write N/A)* Parent #2 / Emergency Contact Information:#2 Parent/Guardian* First Last Relationship to Child #2 Parent/Guardian Cell Phone*#2 Parent/Guardian Email #2 Parent/Guardian Business Phone #2 Parent/Guardian Address if different from your child:*You may leave this blank if not applicable Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation (if not applicable leave blank) Employer (if not applicable leave blank) Work Hours (if not applicable leave blank) Employer/Place of Work Address (if not applicable leave blank)(if not applicable write N/A) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do either of you work for a large corporation?* Yes No Who?*(if not applicable write N/A) Which Corporation?*(if not applicable write N/A) How did you hear about SHED Children's Campus?* Sibling Information:Does your child have siblings?* Yes No Siblings Name First (if not applicable write N/A)Siblings Age (if not applicable write N/A)Siblings Name First Siblings Age Siblings Child Care Program(if not applicable write N/A) Siblings Child Care Program Phone Number(if not applicable write N/A) Does your child have any pets? Please indicate what languages are spoken at home:(if not applicable write N/A) SHED Children's Campus FIRST AID, CPR, EMERGENCY MEDICAL CARE, AND PHOTOS AUTHORIZATION AND CONSENT FORM 2023-2024Child's Name* First Last Date of Birth* MM slash DD slash YYYY First Aid & CPR Consent*I understand that the SHED Children’s Campus staff are trained in the basics of First Aid & CPR and I authorize them to give my child first aid when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. I hereby authorize SHED Children’s Campus to call my physician and/or secure necessary medical care in case of illness or accident, to administer first aid, and CPR, when I cannot be reached and/or a delay, would be dangerous to the protection of my child. If I cannot be reached, I authorize SHED Children’s Campus to accompany my child in an ambulance transport to the nearest hospital for medical treatment including administration of anesthesia if surgery is advised by a physician. I agree to and fully understand the following policies.Name of Hospital* Child Physicians name:* Phone*Physicians Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Health Insurance Coverage:* Policy #* Child’s Allergies:*(if not applicable write N/A) Chronic Health Conditions*(if not applicable write N/A) Is there anything that triggers or complicates this situation? Is there anything that your child should avoid doing? What is it / Are there any medical limitations that we should be aware of? Are there things that you find can make the situation worse? Are there things that you find can make the situation better? SHED, INC. Permission Form for Use of Minor's Picture On the Internet(A minor is any person 17 years of age and younger.) This letter is a request for permission to use photographs of your child on the: • Official SHED, Inc. Web Site on the Internet • SHED, Inc. Facebook, Instagram & Twitter page on the Internet • In SHED, Inc. promotional literature. The images are used on the Internet to promote a wide range of activities, however; the use of images is strictly controlled to best assure safety and confidentiality. Images displayed on the Internet will not be identified by name or any other identifying information. Please return the form on the back to indicate that your child’s picture may or may not be used on the Internet. This permission will stay in effect until canceled by the parent or guardian. If you wish to cancel your permission and have your child’s picture(s) removed, please contact the Webmaster at 978-684-5055 (Linda) and the pictures will be removed. Allow 3-5 working days for removal. Thank you for your cooperation. Linda Shottes-Bouchard Executive Director SHED Inc. 65 Phillips Street ~ Andover, MA 01810 ~ 978-684-5055 ~ FAX 978-636-4800 ~ www.shedchildrenscampus.orgSHED, Inc. Permission Form for Use of Minor's Picture On the InternetInternet PHOTO Release Consent* Yes, my childs picture may be used No, my childs picture may not be used on the Internet Child's Name* First Last Acknowledgement (if you consented yes)As the parent or legal guardian, I grant SHED, Inc. permission to use my child’s picture on the Official SHED, Inc. Web Site on the Internet, SHED Facebook or Instagram page on the Internet In SHED promotional literature. I understand that at any time, I may have my child’s picture removed by contacting the SHED, Inc. Webmaster. It is agreed that the use of my child’s photograph or photographic image shall in no way be used in any other forum other than for official SHED, Inc. business. I hereby waive any right that I may have to inspect or approve the finished product and the advertising copy and/or other matter that may be used in connection therewith or the use to which it may be applied. I do hereby release, acquit and forever discharge SHED, Inc., its officers, employees, attorneys, representatives, insurers and assigns from any and all demands, cause of action and/or judgments of whatsoever nature of character, past or future, known or unknown, whether in contract or in tort, whether for personal injuries, property damage, payments, fees, expenses, accounts receivable, credit, refunds, or any other monies due or to become due, or damages of any kind or nature, and whether arising from common law or statute, arising out of, in any way, the use of my photograph or photographic image for official SHED, Inc. business through its Website, Facebook page, Patch or SHED, Inc. promotional literature. This release contains the entire agreement between the parties and shall be binding upon and inure to the benefit of the successors and assigns of the undersigned. I have read the following:Parent/Guardian Signature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ
