Parental Release and Consent Form

Family Center Consent and Release Form

Member Information

First Name*

Last Name*

Preferred first name (if different than what was listed above)

Penn Email*

Penn Card number (middle 8 digits)*

Penn Status*

School*

Field of Study

Degree Type*

Program Type

Expected Graduation Date ( i.e month/year)

Are you an International Student?

Address (Include City and Zip)*

Address

Address 2

City/Town*

State/Province

Zip/Postal Code*

Home Phone

Work Phone

Cell Phone

Spouse/Partner Information

Name

Email Address

Phone Number

Emergency Contact Information*

Name*

Relationship to participant (ie. spouse, partner, family member, caregiver, etc.)

Email Address

Cell Phone*

Work Phone

Home Phone

Child Information

I am an expecting parent (I anticipate becoming a parent within the next 6 months)

Name and birth date of child #1, #2, #3, #4, #5, #6 (if expecting parent list due date) *

Does your child receive any Support Services or have any special physical, medical or dietary needs? Allergies? (Please explain briefly.)

Designated Childcare Provider Information

I hereby designate each of the following persons as a “Designated Child Care Provider” for my Child, and I authorize each of these Designated Child Care Providers to provide and be wholly responsible for the care and supervision of my Child in the Family Resource Center: (caregivers, friends, family members, etc.)

Acknowledgment of Risks, Release and Video and Photograph Authorization

I understand and acknowledge that the Family Center is not a daycare center, is not equipped or authorized to provide childcare services, and will not provide or be responsible for, the care or supervision of My Child or any other children who are admitted to the Family Center. I have read, understand and agree to comply with the Family Center’s Guidelines, a copy of which is attached to this Release and Consent.
I agree that my Child, and all other children admitted to the Family Center under my care will be accompanied and supervised by me or my Child’s Designated Child Care Provider at all times, and I will not supervise more than three (3) children, including my own child or children, at one time while at the Family Center. I understand that I and my Child’s Designated Child Care Provider are responsible for ensuring that the child or children in our care comply with the Guidelines and other rules governing activities within the Family Center.
I understand that in the event I violate any of the above requirements or any of the Guidelines, or if I or my Designated Child Care Provider(s) or any child under our care or supervision otherwise take any action, deemed inappropriate by Family Center staff, I, and any children under our care or supervision, may be removed and barred further entry from the Family Center.
I understand that neither the Family Center nor the University provides health, accident or liability insurance to my Child or me. I certify that I have adequate medical coverage for any medical services that may be required while I and my Child or children are participating in activities at the Family Center.
In the event that my Child requires medical care, including surgery or administration of drugs, blood or anesthetic and I cannot be reached or the emergent circumstances do not allow time to reach me, I authorize each of the Designated Child Care Providers designated herein to obtain for my Child such medical services as are deemed necessary. I understand and agree that neither the Family Center nor the University assumes any responsibility for any injury or damage which might arise out of or in connection with such emergency medical treatment.
I agree to allow the Family Center to release my name and email address to a third party vendor so that I can access childcare resources and benefits.
I understand that photographs, video recordings or audio recordings may be taken of me and my Child or children during our participation in Family Center activities and I agree that the Family Center and the University of Pennsylvania, and those acting on their behalf, may use, publish and distribute any such photographs, video and/or audio recordings of me or my Child or children and that I will not receive any payment or other compensation for such use. Further, I understand that such photographs, video and/or audio recordings, may be used in any media, including on the Web and in printed materials, in connection with efforts publicizing, promoting or otherwise directly related to the objectives of the Family Center or the University.

I agree to assume all the risks and responsibilities surrounding my Child's use of the Family Center and participation in its activities and in advance release, hold harmless and, forever discharge the University, the Family Center, and their respective governing boards, officers, agents, employees, (including student workers) (collectively, "Releasees"), from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature which I or my Child/children may have or may hereafter have, arising out of or related to use of the Family Center or participation in any of its activities, except if caused by the sole negligence of the any of the Releasees.

I have signed this Release in full recognition and appreciation of the dangers, hazards, and risks of my Child participation in activities at the Family Center, which could include serious injury and property damage. By signing this Release, I acknowledge and represent that: I have fully informed myself of its content and meaning and I understand it; and I am signing it voluntarily and with the intent to be bound. I further agree that this Release shall be construed in accordance with the laws of the Commonwealth of Pennsylvania without regard to conflict of laws principles.

Parent/Legal Guardian Name*

Electronic Signature*

Sign above

Family Center Guidelines

The Family Center welcomes all Penn students and post-docs with children and their family members. Our mission is to create a space where student and post-doc families from the University of Pennsylvania community can access resources, information and supportive programming.

PLEASE NOTE: THE FAMILY CENTER IS NOT A DAYCARE CENTER. WE ARE NOT EQUIPPED OR AUTHORIZED TO PROVIDE CHILDCARE SERVICES, AND WILL NOT PROVIDE OR BE RESPONSIBLE FOR THE CARE OR SUPERVISION OF CHILDREN WHO ARE ADMITTED TO THE FAMILY CENTER.

All families and children use the Family Center at their own risk and assume full responsibility for personal injury to self and family members, and further release Penn and the Family Center for injury, loss, or damage arising out of the use of the facility or other third parties. Each child's parent or other legal guardian must register and electronically sign the Family Center's consent and release prior to using the Family Center for the first time.

All children under the age of 18 must be accompanied and supervised at all times by his or her parent, legal guardian, or designated childcare provider (defined below). No adult may supervise more than three (3) children at one time at the Family Center. This includes designated childcare providers. In the event a child is left unattended, or an adult otherwise violates these requirements, the child and accompanying adult may be required to leave the Family Center immediately.

The Family Center reserves the right to refuse entry to any person, or require any admitted person to leave the Family Center immediately, in the event that a member of the Family Center's staff determines (in his or her sole discretion) that the person's behavior (or the behavior of a companion of such person) is overly disruptive or aggressive, and violates any Family Center rules, any University policy, or is otherwise inappropriate. If that person is caring for a child, the child will also be obligated to leave. One violation is enough to suspend privileges. Any staff decisions to revoke usage privileges may be appealed by writing a letter to the Director of the Family Center.
Each child admitted to the Family Center must be accompanied and supervised by the child's parent, legal guardian or Designated Childcare Provider. Each Designated Childcare Provider must be designated as such by the child's parent or legal guardian in a Family Center Parental Consent and Release. A signed Release naming the Designated Childcare Provider must be on file with the Family Center in order for a child to be admitted under the supervision of a Designated Childcare Provider.
You must accompany your child(ren) at all times while visiting the Family Center, including trips to the bathroom. Parents and caregivers may not leave their children with Family Center staff.
Family Center property is not to be removed from the facility. Violators will be assessed replacement costs for any lost or missing items. If it is determined that the removal of any item(s) was deliberate, the offender will no longer be admitted to the Family Center.
Families must assume responsibility for damaged items caused by neglect, reckless, or willful actions, and pay for replacement or repairs.
Please wipe items with sanitary cloths after your child is finished playing with Family Center toys. These cloths are provided by the Family Center.
Users of the Family Center must return all items to their proper locations.
The Family Center is not responsible for any property brought into the Family Center. A lost and found box may contain misplaced items.
In the case of an emergency, please notify the Family Center staff immediately and call 911 or the University of Pennsylvania Police at 215-573-3333. There is a first aid kit in the Family Center.
All violation of these rules or similar incidents (injury, theft, inappropriate behavior, etc.) must be promptly reported to the Family Center staff.
The Family Center hours are 9:00 am to 6:00 pm Monday through Friday during the academic year. The Family Center will be closed on all University holidays and for occasional maintenance. Refer to the posted Family Center calendar for specific dates.

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