| OFF PREMISES FORM |
| OFF PREMISES FORM I HAVE SCHEDULED IN MY DAY PLAN DAILY WALKS. WE WILL WALK DOWN AND AROUND XXXXXXXXXX DR. AND XXXXXXXXX DR. IF WEATHER IS INCLEMENT WE WILL NOT DO THIS ACTIVITY. DURING WALKS WE WILL CONDUCT TREASURE HUNTS, SING, AND MIMIC. THESE WILL NOT BE JUST A "WALK", THERE WILL BE EDUCATIONAL ACTIVITY INVOLVED. THIS PROVIDES CHILDREN WITH FRESH AIR, EXERCISE, LEARNING TO BE AWARE OF ENVIRONMENT AS WELL AS JUST LEARNING. BY SIGNING THIS FORM YOU WAIVE PROVIDER STATED BELOW FROM ALL RESPONSIBLITY OF ANY INJURY OF STATED CHILD BELOW WHILE OFF PREMISES STATED BELOW. THIS FORM IS ONLY USED FOR DAILY WALKS LISTED ABOVE. PARENT/GUARDIAN CONSENT SIGNATURE: DATE MOTHER______________________________________________________________________________ FATHER:______________________________________________________________________________ GUARDIAN 1:__________________________________________________________________________ GUARDIAN 2:__________________________________________________________________________ CHILD:________________________________________________________________________________ PROVIDER SIGNATURE: DATE: ______________________________________________________________________________________ PREMISES ADDRESS: STREET:______________________________________________________________________________ CITY:____________________________________STATE:________________________ZIP:___________ |
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| I HAVE THIS FORM IN MY WELCOME PACKET FOR PARENTS AND/OR GUARDIANS. WHEN FILLED OUT I MAKE A COPY AND PLACE ORIGINAL IN CHILDS FILE AND GIVE COPY TO PARENT/GUARDIAN. |
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