ProcessedDate______________ Start Date____________________ Willamalane No-School Day Registration Form Child Name______________________________________________Age____Grade in Sept. ____ Birth Date______________________ Address_________________________________________________Zip_____________Home Phone_____________________________ Mother/Guardian Name___________________________________Employer__________________________Work Phone___________ Address_____________________________________Cell Phone______________________E-Mail_______________________________ Father/Guardian_________________________________________Employer__________________________Work Phone___________ Address_____________________________________Cell Phone_____________________E-Mail________________________________ How did you hear about Willamalane? A Friend Internet Search Returning Participant Flier from School Brochure Basic Participant Information: The following questions are designed to help us understand your child’s individual needs. The child care environment is different from both home and school and we want to set your child up for success. Please answer honestly and completely. Attach any other information that will help us prepare for your child’s attendance. Once registered, you may receive additional information and forms to complete and bring with you on your child’s first day. Allergies (list all allergies, plus reaction and treatment) _______________________________________________________________ Physical limitations_____________________________________________________________________________________________ Special behavioral or developmental considerations__________________________________________________________________ Any unusual family circumstances the staff should know______________________________________________________________ Other physical or emotional issues, special needs, etc. ________________________________________________________________ Does your child take any medications? Y or N If yes, please list ______________________________________________________ Is your child currently under the care of a physician for an ongoing medical condition? ___________________________________ If so, please clarify _____________________________________________________________________________________________ Other than those listed above, who is authorized to pick up your child or be contacted in case of emergency during program hours? (please list at least two): Name_________________________________________________Phone__________________Relationship________________________ Name_________________________________________________Phone__________________Relationship________________________ Name_________________________________________________Phone__________________Relationship________________________
Physician_____________________________________________ Phone___________________ Dentist_______________________________________________Phone___________________ For Office Use Only General Information Form (filled out completely) Parent requested Accommodation Form Y or N (Includes signature, date and DL#) Y or N Car/Booster Seat Form (when applicable) Y or N Received Handbook Y or N Medication Release Y or N Child REQUIRES Life Jacket (ages 6-11) Y or N Court Orders Y or N (If yes, attach a copy of the order) Fee Waiver AFS* Other Permission Slip (when applicable) Y or N I _______authorize_______do not authorize staff at Willamalane Park and Recreation District to administer over-the-counter (OTC)
medications (nonprescription) to the above-named minor at the label-indicated dosage. I understand that any OTC medication administered
I _______authorize_______do not authorize staff at Willamalane Park and Recreation District to administer over-the-counter (OTC)
will be recorded and communicated to me. Willamalane Park and Recreation District has a supply of the following medications: children’s
medications (nonprescription) to the above named minor at the label-indicated dosage. I understand that any OTC medication administered
acetaminophen (Tylenol), diphenhydramine (Benedryl) and ibuprofen (Motrin). To my knowledge, all allergies for the named participant
will be recorded and communicated to me. Willamalane Park and Recreation District has a supply of the following medications: children’s
acetaminophen (Tylenol), diphenhydramine (Benedryl) and ibuprofen (Motrin). To my knowledge, all allergies for the named participant are
Parent/Guardian Printed Name___________________________________________Signature________________________________ Parent/Guardian Printed Name___________________________________________Signature__________________________________ Height of child____________ Weight of child____________ Date of last tetanus shot____________________________________ Height of child____________ Weight of child____________ Date of last tetanus shot______________________________________ *AFS patrons will be billed for programs registered. If you wish to discontinue enrollment, you must call our office, giving a two- week notice. If notification is not given, or if AFS will not provide payment, you will be responsible for the entire unpaid balance. If payment is not made and we are forced to send your account to a collection agency, your fees will be doubled to cover collection costs. AFS patron initials __________ Caseworker Name___________________________Extension______________________________
Please Read Carefully By registering my child for a Willamalane program, I agree that I am responsible for the payment of all program fees and costs as set forth in the program payment schedule and all the information described in the handbook. If my account is assigned to a collection agency, I agree to pay all collection costs, including fees to the collection agency. If my account is placed in the hands of an attorney for collection, I agree to pay the reasonable attorney fees and collection costs, regardless of whether an action is filed, and if an action is filed, I agree to pay Willamalane’s reasonable attorney fees at trial and on any appeal there from. The undersigned releases Willamalane Park and Recreation District from all liability which may arise from the child’s participation in a Willamalane program. The undersigned parent/guardian of child authorizes the district and its employees, agents and representatives to consent to any medical, dental or surgical treatment, including first aid, urgent care, emergency care of any health treatment deemed necessary or advisable under the circumstances, for the above-named child. The undersigned also authorizes such person to consent to the transport of the child for health reasons. The undersigned agrees to be financially responsible for and to pay for any such health treatment and transport. The undersigned authorizes Willamalane Park and Recreation District and its employees, agents and representatives to share information about the above-named child with the child’s counselor or therapist, and with any employee, agent or representative of the child’s school district.
ISMP’s List of Confused Drug Names his list of confused drug names, which includes look-alike and sound-alikeThe Joint Commission on Accreditation of Healthcare Organizations (JCAHO) T name pairs, consists only of those name pairs that have been involved in established a National Patient Safety Goal that requires each accredited medication errors published in the ISMP Medication Safety
Dr. BASAVARAJU MANU Assistant Professor, http://www.nitk.ac.in/show/basavaraju-manu PROFESSIONAL EXPERIENCE Assistant Professor, Department of Civil Engineering, NITK Surathkal (October 2009– present). Since 2008: h-index:3 and i-10 index:3 Lecturer, Department of Civil Engineering, NITK Surathkal (December 2007 – September 2009) Reader, Department of Civil Engineering, MIT Ma
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