Kid Central CNY School Break Day Camp

Program Days Applying For

Child Information

Parent/Guardian Information

Emergency Contact/Authorized Pick-Up Information

In the event of an emergency when I may not be reached, Kid Central CNY staff may contact the following individuals whom I authorize to take my child from the child care premises.

Note:  (2) Emergency Contacts are required.

Permissions & Authorizations

The below digital signatures shall constitute an original for all purposes set forth.  Please write full name.

School Break Day Camp Activities Authorization

The child listed has my permission to participate in all Kid Central CNY School Break Day Camp activities.

I understand that Kid Central CNY and their sanctioned members are not liable in case of accident. I understand that every precaution will be taken to provide a safe and secure environment for my child. I assume all risks associated with the activities inherent to those environments.


Emergency Medical Treatment Authorization

I hereby give Kid Central CNY staff members permission to administer basic first aid and/or CPR to my child, as named below, and/or take my child, as named below, to a hospital for medical treatment when I cannot be reached or when delay would be dangerous to my child's health.

Policy Regarding Release of Child

I understand that Kid Central CNY accepts responsibility for my child upon his/her arrival to the program.  Kid Central CNY will not be responsible after my child leaves the program as authorized on the enrollment form.  Children will be allowed to leave the program with persons other than the parent only if written permission has been given to Kid Central CNY staff.  I understand that any changes to the arrival/departure arrangements must be made in writing to the Kid Central CNY staff.

Authorization for Photographs and Video Recording