Sewall Summer Camp Enrollment Form | Sewall Child Development Center

Sewall Summer Program 2023 - Emergency and Permission Information
Child's Name*
Date of Birth*

MonthDayYear
Date
Mom/Guardian's Name*
Address*
Home Phone*
Cell Phone
Work Phone
Email Address 1*
example@example.com
Email Address 2
example@example.com
Special Instructions for Contacting Parent
Dad/Guardian's Name*
Address*
Home Phone*
Cell Phone
Work Phone
Emergency Contact Person*
Relationship to Child*
Home Phone*
Cell Phone
Work Phone
Special Instructions for Contacting Parent
Does your child have any allergies, medical or special needs:*

YesNo
If yes, please list specific needs and/or allergy
Name of Physician
Phone
Name of Dentist
Phone #
Hospital Preference
Insurance Company
Insurance/Medicaid Number
Authorization to Treat
I understand that if I (or any of those listed above) cannot be reached by telephone, and immediate extensive care is indicated, Sewall staff will obtain the necessary medical service. Authorized actions include arranging for ambulance transport to the Children’s Hospital and/or securing a physician. If it is not possible to locate any of the persons listed above, I will assume any expenses incurred.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Sunscreen Permission:*

I give Sewall staff permission to apply sunscreen with an SPF of at least 30 to my child's skin before exposure to outdoor activities. Sunscreen will be provided by Sewall.I do not want any sunscreen applied to my child’s skin.I give Sewall permission to apply ___________________(Please answer the next question) sunscreen, that I will provide, to my child’s skin before exposure to outdoor activities.
If you choose to provide you own sunscreen, please enter the sunscreen you will provide here:
I understand that sunscreen will not be applied to any broken skin or if a skin reaction has been observed. Any skin reaction observed by staff will be reported promptly to the parent/guardian.*

YesNo
Photo Release:*

Yes, I give Sewall permission to use photographsof my child during camp for the purposeof reproduction, publication, or illustration in Sewall publicity media.No, I do not give Sewall permission to usephotographs of my child during camp for thepurpose of reproduction,publication, or illustration in Sewall publicity media.
Other Permission:
I give my child permission to participate in food tasting experiences.*

YesNo
If Yes to the previous question, but my child has dietary/religious restrictions. Please list restrictions:
I grant Sewall permission to take my child on walks on and round the neighborhood as part of the learning curriculum. (Prior to walks, safety and weather conditions will be observed and the Yes center's front desk will be notified of walking routes, departure, and return times*

YesNo
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Covid-19:

Sewall Child Development Center has implemented guidance from the Centers for Disease Control and Prevention, the Colorado Department of Public Health and Environment, Children’s Hospital and Healthy Child Colorado to strive for the safest environment possible for your child while they are in in our care. These steps include hand washing throughout the day and following Sewall’s sick policy (refer to parent handbook). That being said, we cannot reduce the risk of exposure of COVID-19 to zero because each child’s environment outside of Sewall is different and may present varying risks of exposure. If you are not sure if your child should enroll with us at this time, or have any questions about our procedures, please contact our CHO nurse (Fides Carlson) at fides.carlson@childrenscolorado.org 303-549-3513
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Authorization of Release of Child To:
Name
Relationship to Child
Home phone: Cell Phone
Home phone: Cell Phone
Work Phone
Name
Relationship to Child
Home phone: Cell Phone
Home phone: Cell Phone
Work Phone
Should be Empty:

Authorization to Treat

Other Permission: