Common use of Special Information Clause in Contracts

Special Information. 1. Does your child have any food or drug allergies, or special medical needs or conditions? Yes/No If yes, please describe: (attach additional sheet of paper if needed) 2. Does your child currently take prescribed medications on a daily basis for a chronic condition? Yes/No If yes, please describe: (attaché additional sheet of paper if needed) 3. The following special accommodation(s) may be required to most effectively meet my child’s needs while at this center I/we agree that any fees associated with the provision of emergency medical treatment will be my/our responsibility. I/we also agree to keep the CDL advised of any changes in the above information. My/our child may be released to the persons signing this agreement and to the following persons: Name: Relationship to child: Address: Phone Number: (work) (home) Name: Relationship to child: Address: Phone Number: (work) (home) Name: Relationship to child: Address: Phone Number: (work) (home) The following information is asked for identification purposes. In the event that you need to call and authorize pick-up by someone other than those listed above, we will ask you for this information if we are unable to recognize you by voice. Parent/Guardian birthdate: Parent/Guardian birthdate: Maiden/other last name: Maiden/other last name: I/we understand that it is my/our responsibility to keep the center advised of changes in any of the above information. Parent/Guardian Signature Date Parent/Guardian Signature Date Faculty Administrator Signature Date 6/25/2020 I (we) have received and read a copy of the Child Development Lab at the ▇▇▇▇▇▇▇ Center Parent Handbook. I (we) understand and agree to abide by the policies and procedures stated therein. The CDL publishes a family directory every year. This directory provides your home information to other families at the CDL so that you can contact one another at will. This information is not shared with any source outside of the CDL. Please indicate below if you would like to have your information shared with other CDL families. I DO NOT want my personal information shared in the CDL Directory. YES. PLEASE include my personal information in the CDL Directory. 6/25/2020 Parent Signature Parent Signature The Child Development Lab (CDL) at the ▇▇▇▇▇▇▇ Center is a part of the College of Family and Consumer Sciences at the University of Georgia. As a part of our effort to educate the broader community about our research, service, and teaching opportunities, we occasionally participate in presentations and events for positive education purposes concerning the various instructional and extracurricular activities that take place during the year. These presentations/events may include videos, photographs, college and university websites, and articles. These may be used in parent programs, staff development and community relations, such as newspaper articles and TV presentations. The media-- newspaper, radio, television-- sometimes make requests to videotape, interview and/or photograph children for news purposes. Given the age of the children cared for at the CDL, any “interviews” will be limited to simple questions-- such as your child’s favorite part of the day-- and will always take place with a CDL staff member present. It is more likely that your child may be photographed for “feature” photos for the newspaper. I certify that I am the parent or legal guardian of _(print name of child). I hereby grant the Child Development Lab at the ▇▇▇▇▇▇▇ Center the following rights, subject to parent’s right to revoke in writing: The right to use my child’s name, photograph, picture, portrait, likeness, and voice (hereinafter collectively known as “image”) in connection with its educational materials or for any other legitimate purpose; The right to use, reproduce, publish, exhibit, distribute and transmit my child’s image individually or in conjunction with other images or printed matter in the production of motion pictures, media releases, television tape, sound recordings, still photography; and The right to record, reproduce, amplify and simulate my child’s image and all sound effects produced. I understand and agree neither I nor my child will receive compensation, now or in the future, in connection with the use of my child’s image. I hereby release and forever discharge the Child Development Lab at the ▇▇▇▇▇▇▇ Center and the University of Georgia, their members individually and their officers, agents, and employees from any and all claims, demands, rights and causes of action of whatever kind that may have, either in my own behalf or in my capacity as legal representative of my child, caused by or arising from the use of my child’s image, including all claims for libel and invasion of privacy. I understand that acceptance of this Consent and Release Form by the Child Development Lab at the ▇▇▇▇▇▇▇ Center and the University of Georgia shall not constitute a waiver, in whole or in part, of sovereign immunity by said Board, its members, officers, agents, and employees. I certify that I am at least 18 years of age and I have read and understood the above. PARENT/GUARDIAN SIGNATURE DATE PRINTED NAME ADDRESS One of the functions of the Child Development Lab at the ▇▇▇▇▇▇▇ Center is to conduct research by center staff, faculty members, and graduate students. Generally, three types of studies are conducted. 1. Studies of family functioning involve questionnaires, interviews and observations of family interaction. These studies help us to better understand development of interaction patterns in families with young children. 2. Studies of children's groups include observation of groups in classrooms, game- type situations, and interviews with children. These studies help us to understand how social interactions and skills develop and how they affect group dynamics. 3. Studies of individual differences involve studies of perceptual processes, reasoning and logic, and behaviors and processes of personalities. These studies help us to describe stages of development, their progression, and the relationship to personality and social development. All children enrolled in the Child Development Lab are subject to participation in observational studies. Observations of children are conducted by faculty, staff and students both inside the classroom and from the observation booths. For research that requires interactions between children and researchers, or requires children to be taken from the classroom, a separate and specific consent form will be provided to parents. All data is considered confidential and analyses are conducted with coded identifications. Unless we are required by law, no identifiable data regarding any member of your family will be related without your written consent. Research studies at the Child Development Lab are conducted under the supervision of ▇▇. ▇▇▇ ▇▇▇, Director, Child Development Lab. Inquiries about research at the Child Development Lab may be directed to ▇▇▇ ▇▇▇ at (706) 542- 4921. Research at The University of Georgia involving human subjects is conducted under the oversight of the Institutional Review Board. All research conducted at the Child Development Lab is approved by this Board. Questions or problems regarding these activities may also be addressed to: ▇▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇▇, Human Subjects Administrator, Institutional Review Board, Office of the Vice President for Research, The University of Georgia, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇; Telephone (▇▇▇) ▇▇▇-▇▇▇▇. I have read and accept the above information concerning research at the Child Development Lab at the ▇▇▇▇▇▇▇ Center. I agree to participate and give consent for my child to participate in studies conducted at the Child Development Lab. Parent(s) Name or Legally Responsible Person for (child’s name) (Please Print) (Signature & Date) (Please Print) (Signature & Date) 6/25/2020 We are fortunate to serve a diverse population at the Child Development Lab at the ▇▇▇▇▇▇▇ Center and strive to accommodate the needs of every family including any language barriers that may hinder communication. If you speak English as a second language and feel the need for a translator, one will be arranged. My child, , has permission to take walks, stroller rides and/or wagon rides around the University of Georgia’s South Campus with the Child Development Lab at the ▇▇▇▇▇▇▇ Center. I understand that these excursions are informal and notice will be posted in the classroom at the time of the trip (with the notice stating the destination, the time the class left the room and the estimated time of return.) Parent Signature Date Child’s Name Date of Birth Address Parent/Guardian Name Home/Cell Phone Work Phone Parent/Guardian Name Home/Cell Phone Work Phone Persons to notify in an emergency and parents cannot be reached: Name Best Phone Name Best Phone Child’s Doctor Phone Medical facility the center uses: Athens Regional Medical Center Address: ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Child’s Allergies Current prescribed medication(s) Child’s special needs and conditions In the event of an emergency involving my child, and if the CHILD DEVELOPMENT LAB AT THE ▇▇▇▇▇▇▇ CENTER cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child. Child’s Name Signature of Parent/Guardian Witnessed By Date Except for first aid, personnel shall not hand out prescription or nonprescription medications to a child without specific written authorization from the child’s physician. All medications shall be stored in accordance with the prescription or label instructions and kept in places that are inaccessible to children. Each dose of medication given to a child shall be documented showing the child’s name, name of medication, date and time given, and the name of the person giving the medication. Child’s Name Date I hereby give the Child Development Lab at the ▇▇▇▇▇▇▇ Center permission to apply one or more of the following products, in accordance with directions on the container (Check all that apply): Baby Wipes Band-aids Neosporin, Bacitrin or similar ointment Bactine or similar first aid spray Sunscreen Insect Repellent Non-prescription ointment (A&D, Desitin, Vaseline, etc.) Other (please specify): Other (please specify): I hereby request that the Child Development Lab at the ▇▇▇▇▇▇▇ Center administer the checked products in accordance with the directions on the container. Parent/Guardian Signature Date Parent/Guardian Signature Date Family involvement is an essential ingredient for a successful child development program. This form will help define the parent interest areas that can be a classroom resource throughout the year. Read through the following list of information. Choose those activities that interest you and mark the line prior. We appreciate your time and look forward to your visit in our classroom. Accompany class on a field trip Take part in a cooking experience Read or tell a story to children Help with children's garden or playgrounds Invite children to visit your place of work - Workplace: Share cultural customs or traditions (clothing, foods, music, books, etc.) Teach simple words/phrases from a different language - Other - please specify Would you be willing to share these skills with other classrooms beside your child's? Thanks for your contribution! Parent/Guardian: Parent/Guardian: Telephone: (work) (home) Telephone: (work) (home) Best Time to call: Best time to call: Date:

Special Information. 1. Does your child have any food or drug allergies, or special medical needs or conditions? Yes/No If yes, please describe: (attach additional sheet of paper if needed) 2. Does your child currently take prescribed medications on a daily basis for a chronic condition? Yes/No If yes, please describe: (attaché additional sheet of paper if needed) 3. The following special accommodation(s) may be required to most effectively meet my child’s needs while at this center I/we agree that any fees associated with the provision of emergency medical treatment will be my/our responsibility. I/we also agree to keep the CDL advised of any changes in the above information. My/our child may be released to the persons signing this agreement and to the following persons: Name: Relationship to child: Address: Phone Number: (work) (home) Name: Relationship to child: Address: Phone Number: (work) (home) Name: Relationship to child: Address: Phone Number: (work) (home) The following information is asked for identification purposes. In the event that you need to call and authorize pick-up by someone other than those listed above, we will ask you for this information if we are unable to recognize you by voice. Parent/Guardian Mother's birthdate: Parent/Guardian Father's birthdate: Maiden/other last name: Maiden/other last Mother's maiden name: I/we understand that it is my/our responsibility to keep the center advised of changes in any of the above information. Parent/Guardian Signature Date Parent/Guardian Signature Date Faculty Administrator Signature Date 6/25/2020 I (we) have received and read a copy of the Child Development Lab at the ▇▇▇▇▇▇▇ Center Parent Handbook. I (we) understand and agree to abide by the policies and procedures stated therein. The CDL publishes a family directory every year. This directory provides your home information to other families at the CDL so that you can contact one another at will. This information is not shared with any source outside of the CDL. Please indicate below if you would like to have your information shared with other CDL families. I DO NOT want my personal information shared in the CDL Directory. YES. PLEASE include my personal information in the CDL Directory. 6/25/2020 Parent Signature Parent Signature The Child Development Lab (CDL) at the ▇▇▇▇▇▇▇ Center is a part of the College of Family and Consumer Sciences at the University of Georgia. As a part of our effort to educate the broader community about our research, service, and teaching opportunities, we occasionally participate in presentations and events for positive education purposes concerning the various instructional and extracurricular activities that take place during the year. These presentations/events may include videos, photographs, college and university websites, and articles. These may be used in parent programs, staff development and community relations, such as newspaper articles and TV presentations. The media-- newspaper, radio, television-- sometimes make requests to videotape, interview and/or photograph children for news purposes. Given the age of the children cared for at the CDL, any “interviews” will be limited to simple questions-- such as your child’s favorite part of the day-- and will always take place with a CDL staff member present. It is more likely that your child may be photographed for “feature” photos for the newspaper. I certify that I am the parent or legal guardian of _(print name of child). I hereby grant the Child Development Lab at the ▇▇▇▇▇▇▇ Center the following rights, subject to parent’s right to revoke in writing: The right to use my child’s name, photograph, picture, portrait, likeness, and voice (hereinafter collectively known as “image”) in connection with its educational materials or for any other legitimate purpose; The right to use, reproduce, publish, exhibit, distribute and transmit my child’s image individually or in conjunction with other images or printed matter in the production of motion pictures, media releases, television tape, sound recordings, still photography; and The right to record, reproduce, amplify and simulate my child’s image and all sound effects produced. I understand and agree neither I nor my child will receive compensation, now or in the future, in connection with the use of my child’s image. I hereby release and forever discharge the Child Development Lab at the ▇▇▇▇▇▇▇ Center and the University of Georgia, their members individually and their officers, agents, and employees from any and all claims, demands, rights and causes of action of whatever kind that may have, either in my own behalf or in my capacity as legal representative of my child, caused by or arising from the use of my child’s image, including all claims for libel and invasion of privacy. I understand that acceptance of this Consent and Release Form by the Child Development Lab at the ▇▇▇▇▇▇▇ Center and the University of Georgia shall not constitute a waiver, in whole or in part, of sovereign immunity by said Board, its members, officers, agents, and employees. I certify that I am at least 18 years of age and I have read and understood the above. PARENT/GUARDIAN SIGNATURE DATE PRINTED NAME ADDRESS One of the functions of the Child Development Lab at the ▇▇▇▇▇▇▇ Center is to conduct research by center staff, faculty members, and graduate students. Generally, three types of studies are conducted. 1. Studies of family functioning involve questionnaires, interviews and observations of family interaction. These studies help us to better understand development of interaction patterns in families with young children. 2. Studies of children's groups include observation of groups in classrooms, game- type situations, and interviews with children. These studies help us to understand how social interactions and skills develop and how they affect group dynamics. 3. Studies of individual differences involve studies of perceptual processes, reasoning and logic, and behaviors and processes of personalities. These studies help us to describe stages of development, their progression, and the relationship to personality and social development. All children enrolled in the Child Development Lab are subject to participation in observational studies. Observations of children are conducted by faculty, staff and students both inside the classroom and from the observation booths. For research that requires interactions between children and researchers, or requires children to be taken from the classroom, a separate and specific consent form will be provided to parents. All data is considered confidential and analyses are conducted with coded identifications. Unless we are required by law, no identifiable data regarding any member of your family will be related without your written consent. Research studies at the Child Development Lab are conducted under the supervision of ▇▇. ▇▇▇ ▇▇▇, Director, Child Development Lab. Inquiries about research at the Child Development Lab may be directed to ▇▇▇ ▇▇▇ at (706) 542- 4921. Research at The University of Georgia involving human subjects is conducted under the oversight of the Institutional Review Board. All research conducted at the Child Development Lab is approved by this Board. Questions or problems regarding these activities may also be addressed to: ▇▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇▇, Human Subjects Administrator, Institutional Review Board, Office of the Vice President for Research, The University of Georgia, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇; Telephone (▇▇▇) ▇▇▇-▇▇▇▇. I have read and accept the above information concerning research at the Child Development Lab at the ▇▇▇▇▇▇▇ Center. I agree to participate and give consent for my child to participate in studies conducted at the Child Development Lab. Parent(s) Name or Legally Responsible Person for (child’s name) (Please Print) (Signature & Date) (Please Print) (Signature & Date) 6/25/2020 We are fortunate to serve a diverse population at the Child Development Lab at the ▇▇▇▇▇▇▇ Center and strive to accommodate the needs of every family including any language barriers that may hinder communication. If you speak English as a second language and feel the need for a translator, one will be arranged. My child, , has permission to take walks, stroller rides and/or wagon rides around the University of Georgia’s South Campus with the Child Development Lab at the ▇▇▇▇▇▇▇ Center. I understand that these excursions are informal and notice will be posted in the classroom at the time of the trip (with the notice stating the destination, the time the class left the room and the estimated time of return.) Parent Signature Date Child’s Name Date of Birth Address Parent/Guardian Name Home/Cell Phone Work Phone Parent/Guardian Name Home/Cell Phone Work Phone Persons to notify in an emergency and parents cannot be reached: Name Best Phone Name Best Phone Child’s Doctor Phone Medical facility the center uses: Athens Regional Medical Center Address: ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Child’s Allergies Current prescribed medication(s) Child’s special needs and conditions In the event of an emergency involving my child, and if the CHILD DEVELOPMENT LAB AT THE ▇▇▇▇▇▇▇ CENTER cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child. Child’s Name Signature of Parent/Guardian Witnessed By Date Except for first aid, personnel shall not hand out prescription or nonprescription medications to a child without specific written authorization from the child’s physician. All medications shall be stored in accordance with the prescription or label instructions and kept in places that are inaccessible to children. Each dose of medication given to a child shall be documented showing the child’s name, name of medication, date and time given, and the name of the person giving the medication. Child’s Name Date I hereby give the Child Development Lab at the ▇▇▇▇▇▇▇ Center permission to apply one or more of the following products, in accordance with directions on the container (Check all that apply): Baby Wipes Band-aids Neosporin, Bacitrin or similar ointment Bactine or similar first aid spray Sunscreen Insect Repellent Non-prescription ointment (A&D, Desitin, Vaseline, etc.) Other (please specify): Other (please specify): I hereby request that the Child Development Lab at the ▇▇▇▇▇▇▇ Center administer the checked products in accordance with the directions on the container. Parent/Guardian Signature Date Parent/Guardian Signature Date Family Parent involvement is an essential ingredient for a successful child development program. This form will help define the parent interest areas that can be a classroom resource throughout the year. Read through the following list of information. Choose those activities that interest you and mark the line prior. We appreciate your time and look forward to your visit in our classroom. Accompany class on a field trip Take part in a cooking experience Read or tell a story to children Help with children's garden or playgrounds Invite children to visit your place of work - Workplace: Share cultural customs or traditions (clothing, foods, music, books, etc.) Teach simple words/phrases from a different language - Other - please specify Would you be willing to share these skills with other classrooms beside your child's? Thanks for your contribution! Parent/Guardian: Parent/Guardian: Telephone: (work) (home) Telephone: (work) (home) Best Time to call: Best time to call: Date: