Bridges of Silence Educational Center
Summer Reading Camp
Registration Packet
Child’s Name___ Enrollment Date  Date of Birth 
School Name_______________________Grade_____________Female_________Male__________
Parent/ NameHome phone 
Address City__________________________Zip Code___________
Employer_____________________________________Occupation__________________________
Business Phone___________________Ext___Cell/Pager_________________________________
Parent/ NameHome phone 
Address City__________________________Zip Code___________
Employer_____________________________________Occupation__________________________
Business Phone___________________Ext___Cell/Pager_________________________________
Parent Signauture_______________________________________________________________
IN CASE OF EMERGENCY CONTACT: (List two just in case the first one cannot be contacted)
1) Name of Person ______________________________________ Relationship ________
City ________________________________________________ Telephone (_____)______
2) Name of Person ______________________________________ Relationship _________
City ________________________________________________ Telephone (_____)_______
Activities in which you do not want your child-involved in.____________________________
___________________________________________________________________________
Parent’s Signature: ____________________________________________Date: _______________
Bridges of Silence Educational Center
Summer Reading Camp
Registration Packet
Hospital Name____________________________ Insurance card #____________________
Authorizations and Consents
Please initial by the statements for which you give authorization and consent for you child.
____I hereby grant permission for my child to leave the center premises under the supervision of a staff
member for excursions and field trips for which I am pre-notified. If transportation is involved, all vehicles
and drivers will be screened for safety and proof of motor vehicle insurance.
____ I hereby give my permission for my child to be photographed or video/audio taped by staff or media
personnel for the purpose of safety, observation, publicity, research, and new/industry reporting, etc.
without financial compensation or obligation.
____ I hereby grant permission for my child to be included in observations of developmental abilities and
center evaluations.
____ I hereby agree to comply with the rules and regulations specified in the Bridges of Silence handbook
and the policy/payment agreement issued by the center.
____ I hereby grant permission for the center personnel to take whatever steps may be necessary to obtain
emergency safety or medical care for my child. These steps include but are not limited to the following:
1) Attempt to contact a parent guardian or other emergency contact.
2) Attempt to contact the child’s physician.
3) If we cannot contact you or the child’s physician, we will
a) Call another physician or paramedics and /or
b) Have the child taken to emergency hospital in the company of staff of a staff member
(whenever possible).
I understand that in the event of extreme emergency, 911 will be contacted first followed by the contact to
the parent, guardian or emergency contact. I grant permission for a trained staff member to administer First
Aid and/or CPR if necessary until medical professions intervene without liability to the administering staff
member. I understand that any expenses incurred in the above course of action will be my responsibility.
Any eligible expenses will be covered by the centers insurance plan.
__________________________________
Signature of Parent or Guardian
______________________
Date
Authorized pick up persons
Name: ______________ __________________________ ___________Phone__________________
Name: ______________ __________________________ ___________ Phone__________________
Name: ______________ __________________________ ___________ Phone__________________
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Bridges of Silence Educational Center
Summer Reading Camp
Registration Packet
MEDICAL AND LIABILITY RELEASE
Please complete this form for each Bridges of Silence member each enrollment year; leaders to not need to
complete this side. It will stay on file.
Name: ___________________________________________________________________________
Parent’s or Guardian’s Name:
___________________________________________________________________________
1) Is your child on medication? If so, please list types and dosage:
___________________________________________________________________________
2) Is your child allergic to any medication? If so, please list types:
___________________________________________________________________________
3) List any special health conditions:
___________________________________________________________________________
4) Physician’s Name: ______________________________________ Phone: (_____)_____
Hold Harmless Release: In consideration of allowing my child, ________________________, to
participate in the Bridges of Silence program, I assume all risks in connection with the activities involved
and agree to release Bridges of Silence and their employees, for any injury or damage which may befall
________________ while he/she is participating in said activities whether foreseen or unforeseen. I hereby
release Bridges of Silence, and their employees, from any and all action, causes of action, claims, damages,
cost, expenses, compensation, personal loss or any other loss or injury received or incurred by
________________________ during his/her participation in schedule Bridges of Silence programs in
2013-2014. I agree to hold all listed parties harmless from any claim by me or my family, estate, heirs or
assigns arising out of ___________________________ participation in these activities.
I have read the contents of this affirmation and understand its contents. I understand that with any activity
there is a potential for injury or damages to participants.
Signature of Parent/Guardian ________________________________________________ Date
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Bridges of Silence Educational Center
Summer Reading Camp
Registration Packet
Dear Parent:
Your child was recently enrolled in a child program that is licensed by the Colorado Department of Social
Services. The license indicates that the program has met the required standards for the operation of a child
care facility. If you have not done so, please ask to see the license.
Most licensed facilities make every effort to provide a safe and healthy environment for children.
Unfortunately, on rare occasions, an incident of physical or sexual abuse may occur. If you believe that
you child has been abused, you should seek immediate assistance from your county department of social
services. The telephone number to report child abuse in you county is:
Adams County Social Services
Day 303-412-8121 Evening 303-412 5045
7190 Colorado Blvd Commerce City, CO 80022
Colorado requires that child care providers report all known or suspected cases of child abuse or neglect.
Child care services play an important role in supporting families, and strong families are the basis of a
thriving community. Your child’s educational, physical, emotional, and social development will be
nurtured in a well planned and run program. Remember to observe the program regularly, especially
regarding children’s health and safety, equipment and play materials, and staff. For additional information
regarding licensing, or if you have concerns about a child care facility, please consult the Colorado Office
of Child Care Services at 303-866-5958.
Please bring your
immunization records!
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