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484.264.2916

hello@reddoorelc.org

4777 Saucon Creek Road

Center Valley, PA 18034

7:30 am - 6:00 pm

Monday to Friday

logo

484.264.2916

info@reddoorelc.org

4777 Saucon Creek Road

Center Valley, PA 18034

7:30 am - 6:00 pm

Monday to Friday

Medical History, Emergency & Release Form

I have read - and do understand - the information above regarding immunizations in PA.*

Age Appropriate CURRENT immunizations are required for attendance at Red Door. Not providing the appropriate documentation will result in your child being taken off of our enrollment roster until which time the documentation is received in our office. Deposits/Down Payments are non-refundable.

I have forwarded an official copy to the Red Door office.*no

If No:
I will provide the required documentation no later than one week before the start of summer camp - or one month before the start of school - or forfeit my child's enrollment until the documentation is in place. I realize that the deposit is non-refundable should this occur.




Child's Information





Guardian's Information

Do parents/guardians reside with child?
yesno





Physician Information





Bathroom Habits

For Pre-School, PS+, K-Kids and Summer Camp, Children must be fully potty trained.

My Child:
Is completely potty trainedIs not potty trainedStill has urinary accidentsStill has bowel accidentsHas fears about using the toilet





Medical Details

Child's Current Medical Conditions:
No medical issues at this timeFood AllergiesSeasonal AllergiesUses an EPI-PenUses and inhalerUses a nebulizerBed wettingVision IssueWears corrective lensesHearing IssueWears a hearing aidDigestive ConditionCardiac ConditionAsthma/Pulmonary ConditionSkin ConditionBone or muscle conditionEmotional: Fears/Worries/PhobiasSeparation AnxietySleep IrregularitiesSensory Processing ChallengesAutism DiagnosisAsperger's DiagnosisMy child receives support services from a speech therapist/physical therapist/private agency therapist /TSSIf above is checked: My child will receive services at Red Door during the school day.My child has an IEP; We will share IEP goals with the Program DirectorsOther

No Food and/or Seasonal Allergies at This Time







Emergency Contacts




Authorized Caregivers

THE FOLLOWING PEOPLE ARE AUTHORIZED TO DROP OFF AND PICK UP MY CHILD AT RED DOOR.

YOU MUST PROVIDE A PHOTO AND CAREGIVERS ARE EXPECTED TO SHOW PHOTO ID UNTIL WHICH TIME OUR TEACHERS ARE FAMILIAR WITH THEM.






Release Agreements

HOLD HARMLESS AGREEMENT: I/We understand that Red Door Early Learning Center @ (or Red Door”) takes reasonable precautions to insure that its activities are conducted by qualified personnel in a safe and responsible manner. However, I/We further understand that these activities involve certain risks and exposures, which may include but are not limited to: insects, animals, and weather conditions. I recognize these risks and agree to an assumption of them by allowing my child to attend Red Door and participate in any classes, camps or extra-curricular programs. I hereby release, indemnify and hold harmless Red Door Early Learning Center, its officers, trustees, agents, and employees from and against all losses, claims, actions, costs, expenses and/or damages, including attorney and medical fees, arising out of my/our child’s participation in Red Door classes, Summer Camp or sponsored extra-curricular activities, their related risks, whether arising from an act or omission, negligent or otherwise, to the fullest extent permitted by law, except for the willful misconduct or gross negligence on part of Red Door. Permission is granted for my child to participate in Red Door’s program and I understand that by signing below, I am voluntarily and knowingly accepting responsibility for my child’s participation in the Red Door program and its related risks.

BEHAVIOR POLICY: If a student/camper consistently refuses to follow school/camp rules or puts him/her or others in danger, then Red Door reserves the right to dismiss this student/camper from the program without a refund. By signing below, I am acknowledging that I agree to these conditions.

MEDICAL WAIVER: I/ We do hereby authorize the staff of Red Door to act on my behalf, in lieu of my absence to make such decisions, in seeking medical treatment or medicine for my son/daughter, during any Red Door-sponsored class or activity.

PLEASE CHECK THE FOLLOWING. DOING SO INDICATES YOUR AGREEMENT.*

I agree to the Hold Harmless AgreementI agree to the Behavior PolicyI agree to the Medical Waiver



Photo Release

I hereby authorize Red Door Early Learning Center @ LSUCC, hereafter referred to as "RDELC," to publish photographs taken during the school year of myself and/or the minor child or children listed below, and our names and likenesses, for use in the RDELC's print, on-line and video-based marketing materials, as well as other Company publications.

I hereby release and hold harmless RDELC any reasonable expectation of privacy or confidentiality for myself and for the minor child and children listed below associated with the images specified above. Further, I attest that I am the parent or legal guardian of the child or children listed below and that I have full authority to consent and authorize RDELC to use their likenesses and names.

I further acknowledge that participation is voluntary and that neither I, the minor child, or minor children will receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other RDELC publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.

I hereby release RDELC, its contractors, its employees and any third parties involved in the creation or publication of RDELC publications, from liability for any claims by me or any third party in connection with my participation or the participation of the minor children listed below.

Typing your name here indicates that you give authorization to the above PHOTO RELEASE .

List names of minor children whose image may be used for RDELC publicity reasons:

I/We DO NOT give permission for Photo Release

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