Child Care Authorization Form printable pdf download

Child Care Authorization Form

FOX MILL SWIM CLUB

Child Care (Baby-Sitter) Authorization Form

DATE: __________________________________________________________________

NAME OF PARENT/GUARDIAN:_______________________________________________

ADDRESS:________________________________________________________________

EMERGENCY CONTACT PERSON:___________________________________________

PHONE NUMBER:_____________________(H) _______________________________(W)

NAME OF CHILD CARE PROVIDER (Baby-Sitter):_______________________________

ADDRESS:_____________________________________________________________

Names of Children:

1.________________________________________ Age: ________________________

2.________________________________________ Age: ________________________

3________________________________________ Age: ________________________

__________________________ is authorized to care for my children at the Fox Mill Swim

Club.

I give permission for the children listed above to receive emergency medical treatment in the

event that I cannot be contacted. The Fox Mill Swim Club will not be held responsible for any loss

of property or any type of personal injury.

Signed: _________________________________ Date: _______________________

NOTE: Since the pool cannot be a party to anything which would distract sitters from their

appointed duties, sitters may not swim except to accompany children into the pool in a teaching

role. The sitter must be familiar with pool rules, a competent swimmer, and a reliable person. A

baby-sitter may supervise a maximum of three children. Members are responsible for the

conduct of their children who attend the pool accompanied by a baby-sitter, as well as for the

conduct of the selected baby-sitter. It is the member's responsibility to ensure that the pool

management has an accurate phone number to reach the parents or authorized individual.

Print and complete application form and return to the pool office.

Child Care Authorization Form