PLAYSCHOOL
PARENT MANUAL
Revised 3/31/2014
2014-2015
(AGES 3 - 5)
Sharron Baucom Dale City Rec Center
14300 Minnieville Road
Dale City, Virginia 22193
703-670-7112
Ben Lomond Community Center
10501 Copeland Drive
Manassas, Virginia 20109
703-792-8320
Veterans Memorial Park
14300 Veterans Drive
Woodbridge, Virginia 22191
703-491-2183
Chinn Aquatics & Fitness Center
13025 Chinn Park Drive
Woodbridge, Virginia 22192
703-730-1051
1
Table of Contents
PHILOSOPHY .................................................................................................................................. 4
CURRICULUM ................................................................................................................................ 4
PARTICIPANT QUALIFYING SKILLS ........................................................................................... 4
PRESCHOOL CHILD FIND PROGRAM ........................................................................................ 4
CHILDREN WITH SPECIAL NEEDS ............................................................................................. 5
HOURS ............................................................................................................................................. 5
MONTHLY FEES ............................................................................................................................. 5
PAYMENT ........................................................................................................................................ 5
CANCELLATIONS ........................................................................................................................... 6
TRANSPORTATION POLICY/FIELD TRIP POLICY .................................................................... 6
STUDENT ARRIVALS AND DEPARTURES .................................................................................. 6
LATE FEES ...................................................................................................................................... 6
FOOD POLICY ................................................................................................................................. 7
HOLIDAYS & SCHOOL CLOSINGS ............................................................................................... 7
INCLEMENT WEATHER................................................................................................................ 7
EMERGENCY SITUATIONS ........................................................................................................... 8
COMMUNICATION ........................................................................................................................ 8
LINES OF AUTHORITY .................................................................................................................. 8
HEALTH .......................................................................................................................................... 8
POLICY FOR ADMINISTERING MEDICATION ........................................................................... 8
MEDICATION.................................................................................................................................. 9
POLICY FOR OVER-THE-COUNTER SKIN PRODUCTS ............................................................. 9
DISCIPLINARY STEPS ................................................................................................................... 9
BEHAVIORAL GUIDANCE............................................................................................................. 9
FORBIDDEN STAFF ACTIONS .................................................................................................... 10
PROGRAM DISMISSAL POLICY ................................................................................................. 10
SUSPECTED CHILD ABUSE POLICY ........................................................................................... 11
MISCELLANEOUS INFORMATION ............................................................................................. 11
ONLINE REGISTRATION SYSTEM ............................................................................................. 12
DAILY SCHEDULE AND CURRICULUM .................................................................................... 18
PLAYSCHOOL CALENDAR 2014-2015........................................................................................ 19
AUTHORIZATION FORM ............................................................................................................ 20
REGISTRATION INFORMATION................................................................................................ 21
2
WELCOME!
Veterans Memorial Park Playschool staff would like to welcome you and
your child into our program. Thank you for registering with us! Please
take the time to look through this Playschool Manual and complete the
attached forms. Please collect and turn in the following
paperwork by your child’s first day of Playschool:

The attached Authorization Form (second-to-last page of Manual),

Registration Form (last page of Manual),

School Entrance Health Form

Your child’s birth certificate, proof of birth letter or passport (we
must view original)
You may return the paperwork to the Teachers/Front Desk Staff at the
Veterans Memorial Park.
Our staff is excited about working with you and your children this school
year. We thank you for choosing the Playschool program at Veterans
Memorial Park. We offer play-oriented activities that offer choices and
freedom of expression. Our curriculum includes letter and number
recognition, colors, shapes, art, music and movement, and more. Your
questions and concerns are important to us. Please don’t hesitate to
contact us.
Front Desk
Information
703-491-2183
Leslie Stone
Park Manager
[email protected]
703-491-2183
3
PHILOSOPHY
The Playschool program is designed to provide exciting group experiences for children
ages 3 to 5 in a positive and safe environment. The Playschool program provides
opportunities for your child to develop a positive self-concept; to stimulate creativity;
to encourage curiosity; to promote physical development; to perfect communication
skills and to develop basic learning skills. Playschool is a subsidiary of the Prince
William County Department of Parks and Recreation and therefore has no religious
affiliation.
CURRICULUM
Play is a child's primary vehicle to learning. Young children respond well to small
group and individual activities. Our play-oriented activities offer choices and freedom
of expression. Letters, numbers, colors and shapes are incorporated with daily creative
art, music and movement.
PARTICIPANT QUALIFYING SKILLS
The PWC Department of Parks and Recreation aims to provide the best overall
Playschool program possible. Children enrolled in the PWC Department of Parks and
Recreation Playschool must be the program age by September 30, 2014.
We recommend that your child meet each of the following skills prior to enrollment:
1.
2.
3.
4.
5.
6.
7.
8.
Ability to participate in an environment with an age-specific staff to child ratio.
Potty training is required in our 3 – 5 year old classes.
Able to make the transition from leaving parent within one month.
Be able to participate in our staff to child classroom ratios.
Be able to participate for the duration of the class.
Able to follow simple/single instructions.
Able to eat and dress independently.
Respect others and their property.
PRESCHOOL CHILD FIND PROGRAM
In cooperation with the Prince William County Public Schools, our preschool inclusion
program serves children who are exhibiting delays in several areas of development and
who require class-based special education services. The Child Find program is
currently offered at Sharron Baucom Dale City Recreation Center and Chinn Aquatics
and Fitness Center. They are served by a Preschool Special Education teacher who is
based at our playschool. The special education teacher works with the playschool staff
to meet the child’s specific needs in the least restrictive environment.
4
CHILDREN WITH SPECIAL NEEDS
Prince William County Department of Parks and Recreation programs are inclusion
based activities. We make every effort to work with families to mainstream children
with special needs into any of our programs.
If you are requesting any type of accommodation for your child, you must submit a
written request form found on line at www.pwcparks.org. At minimum, this request
must be received, at least 15 business days prior to the start of the program.
Dependent upon the request and/or type of accommodation requested, participation in
a program may be dependent on scheduling and/or contracting specialized staff, which
could impact days/times child can attend the program.
HOURS
All of the Department Parks and Recreation Playschool programs are partial day
programs; there are no full day options. Each playschool site offers a variety of
programs with varied days/times.
(For specific information regarding Daily Schedules and Curriculum, Holidays,
Teacher Workdays and Half-Days, and Inclement Weather please see related sections).
MONTHLY FEES
A $10/month multiple child discount will be given for each additional child in the same
family. (The monthly fee will be full price for the first child). Siblings may be
registered in any of Veterans Memorial Park Playschool programs.
TIME
DAYS
AGES
FEES
9:30a – 12:30p
T-Th
3 years
$137 month
9:30a – 12:30p
M-W-F
4-5 years
$184 month
9:30a – 12:30p
M–F
4-5 years
$232 month
PAYMENT
Monthly fees must be paid at the Front Desk, by telephone, or online by the
first of the month.
NOTE: See pages 11 -15 for instructions on how to pay online.
5
A $15.00 late fee will automatically be added to your account if payment is not received
by the 1st of the month. Unpaid space will be made available to the next child on the
waiting list beginning the 5th of each month. If you have to leave the program for any
reason and then want to re-enroll at a later date the $40.00 registration fee will apply
with the full month tuition.
CANCELLATIONS
A written request is needed 2 weeks before cancellation date to process all
cancellations. In the case of a refund, a $25 administrative fee will be charged.
TRANSPORTATION POLICY/FIELD TRIP POLICY
All transportation to and from the center will be provided by the child’s
parent/guardian. The Prince William County Department of Parks and Recreation
does not offer any off-site field trips or provide transportation of any kind for our
Playschool Program. At no time is a teacher permitted to transport the children.
STUDENT ARRIVALS AND DEPARTURES
An adult must accompany each child into the Playschool room on arrival. Each child
must be signed out daily. Please be prepared to show identification. A child will not be
released to anyone but parent or legal guardian without written permission. A
custodial parent shall be admitted to any child day program. Such right of admission
shall apply only while the child is in the child day program (63.2-1813 of the Code of
Virginia). Children will be released outside the classroom.
Any extended visits or anyone not on the authorized pick up list must be pre-approved
from the Program manager.
LATE FEES
If you are late to pick up your child/children at dismissal time, you will be charged a
late fee of $5.00. After 15 minutes, it is an additional $5.00 per minute. At this time,
your child will be escorted to the Front Office and supervised by the Program
Supervisor or the Manager on Duty. Late fees must be paid when you pick up your
child. If we have not received a phone call, a teacher will make every attempt to contact
a parent/guardian/emergency contact. If unable to do so within 1 hour of dismissal
time, the child will be turned over to the Prince William County Police Department.
This same procedure will be followed if the child is not picked up for emergencies
including but not limited to inclement weather or natural disasters. If you are running
late, please contact the front desk at 703-491-2183. Please make every attempt to
be on time; the teachers have very little time between classes. Repeat
offenders may be removed from the program at any time at Program
Supervisor’s discretion.
6
FOOD POLICY
Snacks will be provided each day by the Playschool program. The center follows the
most recent nutritional requirements of the United States Department of Agriculture
when selecting snacks. Children are allowed to receive second helpings of snacks. A
current snack menu is posted in each classroom. Please advise us of any food
allergies your child may have or any food your child may not have for
religious reasons. All food brought in for parties or celebrations must be
in original store bought food container.
HOLIDAYS & SCHOOL CLOSINGS
A Playschool calendar for the 2014-2015 school year is included in this manual. We
follow the Prince William County School calendar for scheduled school closings.
INCLEMENT WEATHER
We follow the Prince William County School policy on Inclement Weather:



School Closed – Playschool Closed
School Delayed – Morning Playschool Closed
School early release – Afternoon Playschool Closed
We have built in days into our schedule that will help us accommodate days missed due
to inclement weather. If there are days missed that go beyond this allotment, the
Prince William Department of Parks and Recreation will then make decisions as what
further action needs to be taken, up to and including refunds and or proration of fees.
Any adjustment in fees or refunds would be applied during the month of May.
The chart below shows the days already built into the schedule and that will not be
made up due to inclement weather.
Number or days
program meets
Number of days that
would not be made up
due to inclement
weather
Days that would be subject to
make up/refunds/proration
One Day Per Week
One day
Anything beyond 1 day
Two Days Per Week
Up to Two days
Any time missed beyond 2 days
Three Days Per Week
Up to Three Days
Any time missed beyond 3 days
Four Days Per Week
Up To Four Days
Any time missed beyond 4 days
Five Day Per Week
Up to Five Days
Any time missed beyond 5 days
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EMERGENCY SITUATIONS
In an Emergency Situation, the Playschool staff will make every effort to speak with
parents/guardians directly. If unable to do so, the designated Emergency Contacts will
be contacted. This facility has an Emergency Preparedness Plan that includes
procedures for staff to follow in the case of an emergency. The Emergency
Preparedness Plan is available to the public upon request. To request a copy, please
call the Front Desk at 703-491-2183.
COMMUNICATION
If you need to contact staff immediately, or would like to leave a message with the staff,
please call the Front Desk at 703-491-2183.
LINES OF AUTHORITY
If you have any concerns or questions, please consult the Lead Teacher of your child’s
program. If the answer/action is unsatisfactory, please contact the Park Manager,
Leslie Stone at 703-491-2183 or email [email protected].
HEALTH
Playschool staff will do their best to maintain a healthy environment. Parents can
contribute to this effort by keeping sick children home. Teachers should be notified of
an absence lasting three days or longer.
Please keep your child home if he/she has:
1. A temperature over 100F (must be fever free for 24 hours before returning to
school)
2. Recurrent vomiting or diarrhea
3. Any communicable disease
All allergies or medical conditions, which may limit activities, should be brought to the
attention of the staff. If your child becomes ill while attending Playschool, parents will
be notified in order for pick-up as soon as possible.
POLICY FOR ADMINISTERING MEDICATION
If your child requires prescription and/or nonprescription medication, a Medication
Authorization form must completed by a parent/guardian and/or physician. A
qualified Prince William County Department of Parks and Recreation staff will
administer all age appropriate medication in accordance with the labeled instructions
and in accordance with the Medication Administration Training (MAT).
Over the Counter Medication (OTC) that will need to be administered for less than 10
days require parent/guardian authorization on the Medication Consent form. OTC
medications and prescription medications that will need to be administered for more
8
than 10 days require authorization from both parent/guardian and a physician on the
Medication Consent form.
When authorization for medication expires, the staff shall notify the parent/guardian
that the medication needs to be picked up within 14 days or the parent/guardian must
renew the authorization. Medications that are not picked up within 14 days will be
appropriately disposed of by the Program Administrator or Program Director.
MEDICATION
All medication must be:
 In the original container with the prescription label or direction label attached.
 Labeled with the child’s name, the name of the medication, the dosage amount and
the time/times to be given.
 Any utensils needed to administer must be labeled with child’s name.
POLICY FOR OVER-THE-COUNTER SKIN PRODUCTS
The staff does not administer Sunscreen, Diaper Ointment/Cream or Insect Repellent.
If you feel your child needs any of the above items applied, it must be done before they
arrive.
DISCIPLINARY STEPS
Non-Physical Misbehavior: (examples include yelling at teachers, grabbing toys from
other children, repeatedly not following instructions):
 We use the quit thinking time system. We will explain to the child why they are
in the quit thinking time, count 1-2-3, then quit thinking time is used.
 If it happens more than once during the day, we will notify the parent.
Physical Misbehavior (examples include hitting, kicking, biting):
 Immediate notification of parent (serious bite could mean immediate dismissal
from program).
 Conference with Lead Teacher and parent along with written warning. Program
Director will also be notified.
 Subject to dismissal by both Program Director and lead teacher.
NOTE: The Disciplinary Steps may be modified based on the severity of a child’s
behavior.
BEHAVIORAL GUIDANCE
In order to promote the child’s physical, intellectual, emotional, and social well-being
and growth, staff shall interact with the child and one another to provide needed help,
comfort, support and:
1. Respect personal privacy;
9
2.
3.
4.
5.
6.
Respect differences in cultural, ethnic, and family backgrounds;
Encourage decision-making abilities;
Promote ways of getting along;
Encourage independence and self-direction; and
Use consistency in applying expectations.
Behavioral guidance shall be constructive in nature, age and stage appropriate, and
shall be intended to redirect children to appropriate behavior and resolve conflicts.
FORBIDDEN STAFF ACTIONS
Our program staff is forbidden to do the following:
1. Use physical punishment, such as: striking a child, roughly handling or shaking
a child, restricting movement through binding or tying, forcing a child to
assume an uncomfortable position, or using exercise as a punishment;
2. Enclose a child in a small confined space or any space that the child cannot
freely exit himself; however, this does not apply to the use of equipment such as
cribs, play yards, high chairs, and safety gates when used with children
preschool age or younger for their intended purpose;
3. Allow punishment by another child;
4. Separate a child from the group so that the child is away from the hearing and
vision of a staff member;
5. Withhold or force food or rest;
6. Use verbal remarks which are demeaning to the child;
7. Punish a child for toileting accidents;
8. Punish a child by applying unpleasant or harmful substances.
PROGRAM DISMISSAL POLICY
Dismissal may result from serious disciplinary challenges such as, but not limited to,
profanity, failure to abide by program rules, stealing, and lying, the following
procedure will be followed:



First Offense - Warning (Teacher will talk to child & notify parent)
Second Offense - Conference with parent, child, Teacher, & Program Director
Third Offense - Subject to dismissal from program.
This policy can be modified at the discretion of the Program Administrator and/or
Program Director based on the severity of a camper’s behavior. Refunds will be denied
for such circumstances.
Dismissal may also result from carrying a balance due of fees, repeated late payments,
and/or non-payment. Payment is expected by established registration dates (see page
5 for “Procedures and Payment”). Playschool staff will give parents a verbal and
written reminder that payment is past due. If payment is not made by the first of the
month, Program Director makes one more contact to collect fees. If payment is not
made from that communication, their child’s spot will be forfeited.
10
SUSPECTED CHILD ABUSE POLICY
All Playschool staff members are familiar with the procedures for identifying and
reporting child abuse and neglect. The Playschool Staff is required by law to report any
suspicion of child abuse or neglect to the Social Services Office.
MISCELLANEOUS INFORMATION





Please pack a spare set of clothes each day.
Make sure your child is dressed in comfortable, easy to care for clothing that is
appropriate for the prevailing weather.
Please label all belongings brought to school. Lost items will be kept in the
classroom for a short time.
Children are to wear closed-toe shoes every day.
We celebrate Birthdays and Holidays. (Please let us know if your child is not
allowed to participate) Any food must be in original store bought food
container.
ALL POLICIES AND PROCEDURES ARE SUBJECT TO CHANGE.
For Additional Information
Contact the Front desk at 703-491-2183.
11
ONLINE REGISTRATION SYSTEM
Pay program balances on-line for Prince William County Department of Parks &
Recreation Activities!
Pay Program Balances On-Line For
Prince William County Department of Parks & Recreation
Activities!
If you are a new user to our online registration system contact our office at (703) 792-7060 or
[email protected] to request an email containing your username and password. You will be
instructed to update your information the first time you log in.


Log in to www.pwcparks.org
Select Classes & Camps
12
Select Classes & Camps Registration
Enter your User Name and Password
 Click Log In
13
Once logged in, click on My Account
Click on Pay Old Balances
14
To determine program name and start/end dates look under columns labeled Description
and When.

Click on the
picture of the
shopping cart
to the left of the
program you wish
to apply a
payment to.

The selected program will be added to your shopping cart for payment. You can select
Add Another to add additional programs, View Shopping Cart to view selections,
or Proceed to Checkout to make payment.
15
When you are done selecting programs click on Shopping Cart ( ) located on the right hand
corner of screen.

Click on Proceed to Checkout to make payment. You will be prompted to enter your
credit card payment information and print a receipt.
Tip:
If you need to get back to
Shopping Cart at any time
during the payment process click
on “shopping cart” in the right
hand corner of the screen.
16
Enter your Payment Type and Billing Information

Click Finish to complete your transaction and generate a confirmation receipt.
17
DAILY SCHEDULE AND CURRICULUM
Sample Schedules and Subject to Change
4-5’s M/W/F
9:30 – 10:00 Exploration
10:00 – 10:15 Circle Time
11:15 – 11:30
11:30 – 12:15
3’s T/TH
Arrival Play
Circle Time
Exploration (Activity &
Craft)
Snack Time
Outside / Gym
12:15 – 12:30
Story Time & Goodbye
11:55 – 12:20
9:30 – 10:00
10:00 – 10:15
10:15 – 11:15
10:15 – 10:45
Gym / Music & Movement
10:45 – 11:30
11:30 – 11:50
Activities & Craft
Snack Time
Outside / Music &
Movement
Story Time & Goodbye
12:20 – 12:30
9:30 – 10 :00
10:00 – 10:30
10:30 – 10:45
10:45 – 11:30
11:30 – 11:45
11:45 – 12:15
12:15 - 12:30




4-5’s M – F
Arrival / Exploration / Manipulatives
Gym / Music and Movement
Circle Time
Activities / Crafts
Snack Time
Outside Play / Music & Movement
Story Time & Goodbye
Our curriculum "BOOKS THROUGH THE ALPHABET" will include letters, numbers,
colors, shapes and concepts. They will be introduced through books, arts and crafts,
nursery rhymes, games and music.
Circle time will include the day, date, weather, games, songs, sign language, and the
theme of the day will be introduced.
Our hands-on activities are in a learn-and-play environment, will help promote social,
emotional and physical development.
A monthly newsletter will be sent home to inform you of our activities.
18
PLAYSCHOOL CALENDAR 2014-2015
September 2
First Day of Playschool for M-F classes and T/Th classes
September 3
First Day of Playschool for M/W/F classes
October 13
Playschool Closed – Professional Learning Day
November 3
Playschool Closed – Teacher Work Day
November 4
Playschool Closed – Teacher Work Day
November 11
Playschool Closed – Veterans Day
November 26
No Afternoon Playschool – Schools have Half Day
November 27-28
Playschool Closed – Thanksgiving Break
December 22-January 1 Playschool Closed – Winter Break
January 5
Playschool Reopens
January 19
Playschool Closed – Martin Luther King Day
January 23
No Afternoon Playschool – Schools have Half Day
January 26
Playschool Closed –Teacher Workday
February 16
Playschool Closed – Presidents Day
March 30-Apr 3
Playschool Closed – Spring Break
April 6
Playschool Closed – Teacher Workday
May 25
Playschool Closed – Memorial Day Holiday
June 11th
Last Day of Playschool for T/Th classes
June 12th
Last Day of Playschool for M/W/F classes and M-F classes
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AUTHORIZATION FORM





I HAVE READ THE PARENT’S MANUAL AND I AGREE WITH THE
POLICIES AND PROCEDURES OF THE PROGRAM.
I AUTHORIZE VETERANS MEMORIAL PARK STAFF TO SEEK
MEDICAL CARE FOR MY CHILD SHOULD AN EMERGENCY OCCUR
WHEN THE PARENT CANNOT BE LOCATED IMMEDIATELY UNLESS
THE PARENT STATES IN WRITING AN OBJECTION TO THE
PROVISION OF SUCH CARE ON RELIGIOUS OR OTHER GROUNDS.
I UNDERSTAND THAT IF MY CHILD BECOMES ILL I WILL BE
CONTACTED BY THE CENTER; I WILL ARRANGE TO HAVE HIM/HER
PICKED UP AS SOON AS POSSIBLE IF SO REQUESTED BY THE
CENTER.
I WILL NOTIFY VETERANS MEMORIAL PARK WITHIN 24 HOURS OR
THE NEXT BUSINESS DAY IF MY CHILD OR A MEMBER OF THE
IMMEDIATE HOUSEHOLD DEVELOPS ANY REPORTABLE
COMMUNICABLE DISEASE, AS DEFINED BY THE STATE BOARD OF
HEALTH.
I WILL NOTIFY VETERANS MEMORIAL PARK IMMEDIATELY IF MY
CHILD OR A MEMBER OF THE IMMEDIATE HOUSEHOLD DEVELOPS
A LIFE-THREATENING DISEASE.
Child’s Name:
Parent’s Name:
Parent’s
Signature:
Date
Signed:
PARTICIPATION AGREEMENT
The PWC Department of Parks and Recreation assumes no liability for injuries or damages arising from the
result of participation. Due to the strenuous nature of some activities, the participant is urged to consult
his/her physician concerning the ability to participate. All activities present inherent risks and hazards, which
the participant assumes. I hereby approve of my child’s participation in this Recreation Program.
Parent/Guardian Signature:
Date Signed:
20
PWC DEPARTMENT OF PARKS AND RECREATION
2014-2015 PRESCHOOL-AGED
REGISTRATION INFORMATION
Date entered care:
Date left care:
CHILD'S NAME:
ADDRESS:
Program Attending: _________________________________________
Childs Birthday: _______________
MOTHER
FATHER
NAME:
ADDRESS:
NAME:
ADDRESS:
PLACE OF
PLACE OF
EMPLOYMENT:
EMPLOYMENT:
WORK PHONE:
WORK PHONE:
HOME PHONE:
HOME PHONE:
CELL PHONE:
CELL PHONE:
E-MAIL:
E-MAIL:
Previous Daycare Programs and School Attended:
If this child attends this center and another school/program, give name of school/program:
HEALTH/MEDICAL INFORMATION
My child has allergies:
Yes
My child is allergic to the following:
No
No medication needs to be administered to my child during program hours. (initial)
I request the medication(s) described below be administered during program hours, by a PWC Department of Parks and
Recreation, and agree to furnish said medication(s) in the original Pharmacy-labeled container(s).
(1) Medication:
Dosage:
Time:
(2) Medication:
Dosage:
Time:
Parent/Guardian Signature:
Date Signed:
My child may not have the following food for religious reasons:
PHYSICIAN’S INFORMATION
Please fill out the required information below:
Physician’s Name:
Telephone #:
SWIMMING RELEASE
YES, my child has permission to swim during program hours and has completed the swim level listed below.
SWIM LEVEL:
NO, my child does not have permission to swim during program hours.
Parent/Guardian Signature:
Date Signed:
21
INCLUSION INFORMATION:
My child does NOT have any special needs or need any accommodations. (see below)
My child has special needs. (check below)
To request any type of accommodation for your child, you must submit a written request form (available at
pwcparks.org/camps) to the site manager at least 15 business days prior to the start of the program.
ADD
ADHA
ADHD
Additional
Comments/Other:
Developmental Delay
Diabetic
Hearing Impairment
Autism Spectrum Disorder
Physical Disability
Learning Disability
Speech/Language Only
Visual Impairment
Asthma
VIDEO/PHOTO AUTHORIZATION
I give PWC Department of Parks and Recreation permission to include my child in Program photographs/videos. I
understand that these become the property of the PWC Department of Parks and Recreation.
Parent/Guardian Signature:
Date Signed:
EMERGENCY CONTACTS AUTHORIZATION
The PWC Department of Parks and Recreation has my permission, in an emergency, to call 911 and/or send my child to a
hospital/urgent care facility, and the medical personnel have my authorization to provide treatment, which a physician
deems necessary for the wellbeing of my child. The PWC Department of Parks and Recreation will make every
reasonable attempt to contact the Parent/Guardian/Emergency Contacts.
NOTE: EMERGENCY CONTACTS CANNOT BE THE PARENTS/GUARDIANS. PER VIRGINIA
STATE LICENSING REQUIREMENTS, YOU MUST LIST AT LEAST TWO EMERGENCY
CONTACTS.
NAME:
ADDRESS:
Phone #:
Relationship:
NAME:
ADDRESS:
Phone #:
Relationship:
NAME:
ADDRESS:
Phone #:
Relationship:
Parent/Guardian Signature:
Date Signed:
DISMISSAL AUTHORIZATION
Every day at dismissal time, the Parent/Guardian/Authorized Alternate picking the child up MUST SIGN THEM OUT.
No child will be permitted to leave program area with persons other than a Parent/Guardian/Authorized Alternate listed
below. Identification must be presented at time of pick up.
Parent/Custodian
Name:
Authorized
Alternate:
Parent/Custodian
Name:
Authorized
Alternate:
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