Parent/Guardian #1 Information
Parent/Guardian Information 2
Emergency Contacts (do not include legal guardians)
First Aid & Emergency Medical Care Consent
My initials below authorize staff of Roxborough Church—who are trained in the basics of first aid—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. However, if I cannot be reached, I hereby authorize Roxborough Church to transport my child to the nearest medical care facility and to secure necessary medical treatment for my child. I understand that I assume all financial responsibility for any treatment or injuries sustained by my child while he/she is in Roxborough Church care.
Administration of Medication Consent Form
1. All prescriptions and nonprescription medications shall be maintained with the child's name and shall be dated.
2. Prescriptions and nonprescription medications must be stored in the original bottle with an unaltered label. Medications requiring refrigeration must be properly stored.
3. Prescription and nonprescription medication shall be administered in accordance with the label directions.
4. Written consent must be provided from the parent, permitting Roxborough Church staff to administer medications to the child. Instructions shall not conflict with the prescription label or product label directions.
Photograph/Media release authorization on behalf of Roxborough Church:
1. I am enrolling my child in Roxborough Church's programs.
2. I understand there is one-time application fee of $45.
3. I understand there is a tuition fee which is due by the due date via brightwheel or by check. Failure to pay could result in my child losing his/her spot in the program.
4. I understand that Roxborough Church hours of operation are 8:30 am - 3:00 pm
5. I understand that my child will not be dismissed from the program without being picked up by a parent or a designated adult.
6. I understand there will be a $10 fee added every 10 minute segment after 3:00pm
7. I understand that disrespect, fighting, physical and verbal aggression will not be tolerated in this program. I understand that my child could lose his/her position in the program and may be discharged immediately for such actions.
8. I understand that if a medical emergency arises, program staff will attempt to contact parents or the emergency contact that I have indicated. It is my responsibility as the parent/guardian to notify the staff if this information changes. If immediate medical attention is necessary, an ambulance or emergency vehicle may take my child to the hospital.
9. In case of illness, I understand that my child may not be permitted to attend the program. If staff feels that a child has a contagious disease, he/she may not return to the program without a doctor's note.
10. In order for my child to be considered for this program, I understand that I must complete all enrollment paperwork and health assessments.
11. I understand that Roxborough Church's programs are faith-based (Christian).
12. I will receive complete program information (handbook) at the time of enrollment (PA Code 3270.121, 3280.121, 3290.121).
13. I agree to update the emergency contact and parental agreement when changes occur or every 6 months at a minimum (PA Code 3270.124, 3280.124, 3290.124).
Non-discrimination in Services
SUBJECT: Nondiscrimination in Services
FROM: Roxborough Church
Admissions, the provisions of services and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age or sex.
Program Services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.
Any individual/client/patient/student (and/or their guardian) who believes they have been discriminated against, may file a complaint of discrimination with:
8230 Ridge Ave.
Philadelphia, PA 19128
Commonwealth of Pennsylvania Department of Human Services Bureau of Equal Opportunity
Room 225, Health & Welfare Building P.O. Box 2675
Harrisburg, PA 17105
U.S. Department of Health and Human Services
Office for Civil Rights
Suite 372, Public Ledger Building 150 South Independence Mall West
Philadelphia, PA 19106-9111
Dismissal, Discipline, and Discharge Policy