A Program of Andrew Fleck Child Care Services
CONSENT TO CHILD CARE AND RELEASE FROM LIABILITY FORM
representative(s) of ____________________________________________________________________
(name of the child/ren) hereby agree to, assume responsibility for and undertake to abide by the
arrangements with the STCC Program for childcare to be provided by the designated caregiver(s)
(hereinafter referred to as STCC caregiver) of the STCC Program, to take place during the conference/
special event at ____________________________________________________________ (name of
location of conference/special event) under the following conditions:
1. understand that the STCC caregiver is neither a physician nor a nurse and that s-he is not
competent to diagnose any child/ren's illness and s-he will not do so; s-he may administer first aid on an
emergency basis if, on her/his sole discretion, s-he believes it necessary to save the child/ren's life and I/we
hereby consent to same.
2. hereby release the STCC caregiver and the STCC Program from all liability for any
complication(s) which may develop in the child/ren's condition as a result of care given to the child/ren in
accordance with the Instructions For Child Care form which is to be completed, by the parent of each
child, prior to the start of care.
3. hereby give the STCC caregiver permission to care for the child/ren in accordance with the
information provided in the Instructions For Child Care form, including the administration of prescription
and non-prescription drugs provided therein.
4. hereby authorize the STCC caregiver to consent to emergency medical care for the child/ren
should the caregiver, in consultation with a representative of the STCC Program, believe a medical
emergency exists and s-he is unable to or does not have time to contact us for instructions. I/We further
agree that the expense resulting from such a decision by the STCC caregiver to seek emergency care,
(including but not limited to ambulance bills, doctor's fees and hospital charges), will be my/our sole
responsibility and hereby agree to hold the STCC caregiver and the STCC Program harmless from same.
5. hereby authorize the STCC caregiver to use such appliances and/or other items and facilities at the
site of care as may be reasonably necessary in the judgement of the STCC caregiver to provide adequate
care for the child/ren, except as specifically excluded by me/us in writing. I/We further release and agree
to hold the STCC caregiver and the STCC Program harmless from any loss caused by damage to or
breakage of any property when reasonably used by the STCC caregiver as set forth above.
6. hereby agree:
A. to sign this Consent to Child Care And Release From Liability form and submit same to the
STCC caregiver or the representative of the STCC Program PRIOR to the start of child care.