Relationship to Child definition

Relationship to Child. Date: …………………………….. Signature on behalf of Children First: Xxxxx Xxxxxxx Nursery Director

Relationship to Child. DOB: Total Children: Date In: Time In: Date Out: Time Out: Total Hours: OFFICE USE ONLY # of Regular Hours/Rate: # of OT Hours/Rate: Total Hours/Payment: Level of Care: Name of Respite Eligible Child: Caregiver Relationship to Child: DOB: Total Children: Date In: Time In: Date Out: Time Out: Total Hours: OFFICE USE ONLY # of Regular Hours/Rate: # of OT Hours/Rate: Total Hours/Payment: Level of Care: Name of Respite Eligible Child: Caregiver Relationship to Child: DOB: Total Children: Date In: Time In: Date Out: Time Out: Total Hours: OFFICE USE ONLY # of Regular Hours/Rate: # of OT Hours/Rate: Total Hours/Payment: Level of Care: Total Claim Hours Total Claim Payment I acknowledge and understand that payment for the respite provider’s services will be made on behalf of the resource parent by the County of San Diego Health and Human Services Agency. I adhere to the terms and conditions stated on the back of this agreement and I hereby certify that the information on this agreement/claim form is true and accurate. Resource Parent Signature Date Respite Provider Signature Date Reviewed by Respite Program Assistant Date Respite Program Coordinator Date HHSA AGREES TO PAY THE RESPITE PROVIDER: For services rendered upon receipt of a properly completed respite claim form, with payment to occur approximately 6 to 8 weeks after claims have been received and approved. CLAIM FORMS: • Are due no later than 30 calendar days following the month of service. • Original claim forms must be completed, signed, and submitted after the services have been provided. • Total respite care hours will not exceed 100 hours per calendar quarter per resource family. For excess respite hours, the family must obtain pre-approval from the program coordinator. • Unused respite hours do not accumulate month to month. RESOURCE PARENTS: • You must have at least one dependent qualified child placed in your home. • The respite provider cannot live in the same household as the resource parent. • Respite services may not be used to provide respite services to other families. • Options or other County-provided respite services may not be used simultaneously with this respite program. • A resource parent may not provide respite unless their resource home is RFA approved or a licensed xxxxxx home. • A resource parent may not provide overnight respite if they are at capacity. • A resource parent may not provide respite if they have a child specific RFA approval. • A resource parent may not provide re...

Relationship to Child. Email Address: Mobile Number: Work/Alternate Number Physical Address: Postal Address: Parent/s and/or Legal Guardian/s initial/s TERMINATION: - Membership shall be valid for a full calender year, then will continue on a month to month basis, until a new contract is signed. Membership is subject to one month’s written notice, (i.e. notice is for the end of a month) or one month’s fees in lieu of notice to be paid on leaving The Centre. - Annual members need to hand in their notice by the end of October of the current year, November being the notice month, if your child will not be continuing to attend Kids Club the following year. - All notices must be in writing and e-mailed to Xxxxx@xxxxxxxxxxxxxxxxxx.xx.xx, no later than the 1st day of your last attending month. Late notices will NOT be accepted and the relevant monthly fees will apply. - If your child is dropping the number of days attending a week, a minimum of one month’s notice is required. - It is the responsibility of the parent/s and/or legal guardian/s to give The Centre one full calendar month’s notice of termination of enrolment. Cancellation fees will apply according to the industry standard. - This agreement shall also terminate in the event that it is necessary for The Centre to dismiss the child from the premises for whatever reason, including disciplinary reasons or failure by the child to comply with the rules and regulations of The Centre. Parents/guardians will be notified and given 20 business days’s notice to remedy the child’s behaviour, after which, the agreement may be terminated by the school. I have read and understand the rules of the Express!ons Centre and the Express!ons Kids Club and have explained them to my child/ren. We agree to abide by all the rules, regulations and code of conduct of The Centre. I agree to pay fees owed to Express!ons In Focus no later than the 1st of each month. I authorise the facilitators to obtain medical assistance, which they deem necessary should an accident occur, and agree to pay all medical expenses incurred on behalf of the enrolled child. This waiver is unconditional and is given in both my personal capacity and as a father/mother/natural/legal guardian of any minor concerned. Mother / Legal Guardian Name Signature Date Father / Legal Guardian Name Signature Date Parent/s and/or Legal Guardian/s initial/s

Examples of Relationship to Child in a sentence

• I authorize the following responsible persons to pick up my child from the program (attach additional pages as needed): Authorized Person Phone Number Relationship to Child Please note that children must be picked up by designated times.

• Name: Relationship to Child: Street Address: City/State/Zip: Phone/s: c.

• Since IFQ implementation, a variety of scenarios have emerged based largely on whether the participant is an initial recipient of QS, has acquired additional QS, or largely operates as a hired skipper/lessee.

• Please note work (w), cell (c), or home (h) for type Name Primary #/Type Secondary #/Type Relationship to Child Authorization For Medical Treatment:In the event of an emergency, I authorize VCS personnel to make arrangements for my child to receive medical care, including required transportation.

• Phone #: Home Cell Work First Name Last Name Relationship to Child: XII.

• Phone #: Home Cell Work First Name Last Name Relationship to Child: 2.

• Phone #: 🞏Home 🞏Cell 🞏Work First Name Last Name Relationship to Child: 2.

• Name: _ Age:_ Relationship to Child: Last known address: City: State: Zip:_ Home Phone: Cell Phone:_ Court Order: Date: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

• Authorised Nominee’s Name: Address: Ph No: Alternate Ph No: Relationship to Child: Please indicate Yes/No in the relevant boxes for this authorised nominee to authorise consent: Yes/Noto collect your child from the centre and to be contacted in an emergency situation.

• Phone #: 🞏Home 🞏Cell 🞏Work First Name Last Name Relationship to Child: XII.