The American Society of Dowsers
45th Annual Convention
Lyndon Children's Center
(Bring these forms filled in, to the Lyndon Children's Center)
ASD CONVENTION - LYNDON CHILDREN'S CENTER CONTRACT   (2005)

CHILD'S NAME ____________________________________ DOB ________________

PARENT/LEGAL GUARDIAN ______________________________________________

PERSON(S) RESPONSIBLE FOR PAYMENT SIGNATURE _______________________________

      This contract is for the ASD Convention Days, beginning on Tuesday, June 14, 2005 and terminating Friday June 17, 2005*

TUITION RATES:

FULL DAY - $20.00

PRE-SCHOOL - $14.00 (7:30- 12:30)

AFTERNOONS - $14.00 (12:30-5:30)

YOUR ENROLLMENT SLOTS:

Tue ______________________________    Wed.______________________________

Thur. _____________________________    Fri. _______________________________

Sat.* _____________________________

TUITION DUE: ____________________

      PAYMENT MUST BE MADE IN FULL THE FIRST DAY YOUR CHILD(REN) ATTEND.
Returned check policy- There will be a $15.00 charge for every check returned to the center.

*Saturday daycare may be a possibility if at least 6 children attend at 35.00 per child that day.

PARENT/LEGAL GUARDIAN'S SIGNATURE ____________________________________   DATE ______________

DIRECTOR'S SIGNATURE ___________________________________________________   DATE ______________

ASD 45th CONVENTION  - CHILD'S ADMISSION FORM FOR THE LYNDON'S CHILDREN CENTER

Child's Name _________________________________Age _____   DOB__________ Date ___________

Parent(s) or Legal Guardians ____________________________________________________________

With whom does the child reside? ________________________________________________________

Mailing address:  Street_________________________________________________________________

Town/City_______________________________________________   State _____   ZIP _____________

Phone:  Home ______________________ Cell _____________________ Lodging _________________

Parent(s) or Guardian(s) Employment:

__________________________________________ Work phone ______________________

__________________________________________ Work phone ______________________

Emergency Contacts (other than parent)

1) _________________________________ Relation ______________ Phone ________________

2) _________________________________ Relation ______________ Phone ________________

List All People Who May Pick Up Your Child From LCC At Any Time (other than Parent)

1) _________________________________ Relation ______________ Phone ________________

2) _________________________________ Relation ______________ Phone ________________

Does your child have any Dietary Restrictions? ________________________________________

_________________________________________________________________________________

Please List Any Known Allergies _____________________________________________________

Is Your Child On Any Medications? _____ Please explain_________________________________

_________________________________________________________________________________

Does Your Child Have Any Special Toileting Needs? ____________________________________

_________________________________________________________________________________

Does Your Child Have Any Fears? ___________________________________________________

Are There Any Behavior Concerns? ______ (please explain) _______________________________

__________________________________________________________________________________
 

ASD CONVENTION - LYNDON CHILDREN'S CENTER
MEDICAL PERMISSION

CHILD'S NAME: _____________________________________________________________

PARENT(S)/LEGAL GUARDIAN(S) _______________________________________________

PHONE:   HOME ________________ CELL __________________ DORM _______________

CHILD'S PHYSICIAN ______________________________ PHONE ____________________

CHILD'S DENTIST ________________________________ PHONE ____________________

EMERGENCY CONTACT PERSON  1) ____________________________________________

RELATIONSHIP _________________________________ PHONE _____________________

EMERGENCY CONTACT PERSON  2) ____________________________________________

RELATIONSHIP _________________________________ PHONE ______________________

HOSPITAL PREFERENCE _________________________________________

MEDICAL INSURANCE _______________________________GROUP # ________________

LCC MAY USE TOPICALLY APPLIED NON-PRESCRIPTION MEDICATIONS WHEN NEEDED: YES _______   NO ______

I HEREBY GRANT PERMISSION TO THE STAFF OF THE LYNDON CHILDREN'S CENTER TO TAKE WHATEVER STEPS THAT MAY BE NECESSARY TO OBTAIN EMERGENCY MEDICAL CARE FOR MY CHILD IF WARRANTED: THESE STEPS INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:

  1. 1 ATTEMPT TO CONTACT A PARENT OR GUARDIAN
  2. 2 ATTEMPT TO CONTACT THE CHILD'S PHYSICIAN
  3. 3 ATTEMPT TO CONTACT THE PARENT THROUGH ANY OF THE PERSONS LISTED BY THE PARENT AS AN EMERGENCY CONTACT
  4. 4 CONTACT THE RESCUE SQUAD
  5. 5 HAVE THE CHILD TAKEN TO A HOSPITAL EMERGENCY ROOM.
SIGNATURE : ___________________________________________ DATE: _______________
(PARENT/GUARDIAN)

(ON THE BACK OF THE PAPER OR ANOTHER SHEET,  WRITE PERMISSION AUTHORIZING EMERGENCY TREATMENT AT THE HOSPITAL, IF YOU CHOOSE.)

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