Farmington Health Center - Drop-In Child Care - Center for Child Care and Family Resources

Child's Information
Indicates required information

Child's Name
Child's Gender Male Female
Child's Date of Birth(e.g. mm/dd/yyyy)
Child's Age
Does your child use the bathroom unassisted? Yes No Diaper
Add another child? Yes

Second Child's Information

Second Child's Name
Second Child's Gender Male Female
Second Child's Date of Birth(e.g. mm/dd/yyyy)
Second Child's Age
Does your child use the bathroom unassisted? Yes No Diaper
Add another child? Yes

Third Child's Information

Third Child's Name
Third Child's Gender Male Female
Third Child's Date of Birth(e.g. mm/dd/yyyy)
Third Child's Age
Does your child use the bathroom unassisted? Yes No Diaper
Add another child? Yes

Fourth Child's Information

Fourth Child's Name
Fourth Child's Gender Male Female
Fourth Child's Date of Birth(e.g. mm/dd/yyyy)
Fourth Child's Age
Does your child use the bathroom unassisted? Yes No Diaper

Parent Information

Parent/Guardian's First Name
Parent/Guardian's Last Name
Cell Phone(xxx-xxx-xxxx)
Home Address
City
State/Province
Zip/Postal Code

Persons who may be called and/or pick up in case of emergency if parent/guardian cannot be reached

Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Address
Emergency Contact Phone(xxx-xxx-xxxx)
Add another emergency contact? Yes

Add a Second Emergency Contact

Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Address
Emergency Contact Phone(xxx-xxx-xxxx)

Additional Information

Describe any pertinent information or special needs of your child.
Does your child have any allergies, illness or medical conditions we need to be aware of? If so, please explain.

Statement of Understanding

Children may only attend while parent/guardians attend a scheduled appointment at Farmington Health Center and only up to 4 hours maximum.
Picture identification must be given each time parent/guardian checks into drop-in care.
Drop-In Care is only available for children 18 months to 8 years of age.
Sick and mildly ill children may not attend.
Diaper changing services are not available. Nor can a staff member assist or aid any child in the bathroom at any time. Children who are toilet trained will be taken to the bathroom by a staff member but the staff member cannot accompany the child inside the restroom. Parents will be contacted through their mobile device, by texting, prior to and during their scheduled appointment to change all diapers and assist with any needs in the bathroom.
It is required that the parent have their mobile device on and available at all times while visiting the health center and their child remains in care.
Meals and/or snacks are not provided.
Outside food and drink is not permitted. Anything brought in to the drop-in care will be put out of reach of all children.
I understand that my child needs protective footwear of some kind and I agree to provide protective footwear.
Immunization records are not required or reviewed by staff. Children in care may or may not be fully immunized.
I, as the parent or guardian of the child/children listed above, hereinafter referred to as Participant(s) in programming facilitated by University of Utah Health Care, UKids – Farmington (hereafter University of Utah), allow above-named Participant(s) to take part in the drop-in child care activities (hereafter Program) while attending today’s scheduled medical appointment.
It is not the mission of the Center to provide child care for its clients in any location other than at the Center during regular operation hours. Any arrangement for child care which does not take place at the Center is strictly a private arrangement between the parents and the individual staff member. No such private arrangements shall be made for child care on campus or during the work shift of a staff member or interfere with the operation of the Center or the individual’s job performance. Parents and staff should understand that such arrangements are not within the course and scope of the staff member’s job duties and that staff members are free to either accept or reject such requests from parents.
I acknowledge that there are specific risks of injury to persons and/or property including the Participant(s), which are associated with this Program including, but not limited to, inside play activities, and exposure to other children who may have illnesses or who may not be immunized. I voluntarily assume the risk of such injuries and illnesses, and hereby certify and represent that I have secured appropriate personal accident/health insurance coverage for Participant(s) during the period of attending this Program. In case of medical emergency, I authorize the University of Utah to respond as necessary and obtain immediate medical help.
I understand and acknowledge that the University of Utah is not an insurer of Participant(s) behavior and actions and that the University assumes no liability for personal injuries or property damage to Participant(s) or to third persons arising out of University of Utah’s Program. I release the University from liability for any injury or damage which may arise from the Program.
I agree to indemnify and hold harmless the University of Utah and all of their officers, employees and agents from any liability to the University of Utah to the extent caused by the Participant(s).
In accordance with the University Safety of Minors Policy (Rule 1-015) and State of Utah law (Code 62A-4a-403) all authorized adults working with minors are trained in mandatory reporting requirements.
A mandated reporter is a person who is legally required to ensure a report is made when abuse is observed or suspected. The state of Utah designates a Mandatory Reporter as “any person who has reason to believe that a child has been subjected to abuse or neglect” (Utah Code Ann. §62A-4a-403). They do not have to prove that abuse is occurring, just that there is reasonable cause to believe abuse or neglect is occurring. This report must be made to a law enforcement agency or the Division of Child and Family Services.

In addition to notifying law enforcement or DCFS, the Safety of Minors Policy (Rule 1-015) also requires that individuals report known or suspected abuse of a minor during a University program or event, or on University premises, to the Office of Equal Opportunity and Affirmative Action at the University of Utah. All staff members who are to be with minors are required to participate in a OEO/AA Minor Safety and Reporting training prior to employment.

If you, as a parent or guardian, have concerns about any misconduct in connection with a University program or event, please contact the University’s Office of Equal Opportunity and Affirmative Action at (801) 581-8365.

Related links:
https://dcfs.utah.gov/contact/
https://oeo.utah.edu/resources/minors-in-university-programs/
The University of Utah does not discriminate on the basis of race, ethnicity, color, religion, national origin, sex, age, disability, sexual orientation, gender identity, gender expression, genetic information or protected veteran’s status, in employment, treatment, admission, access to educational programs and activities, or other University benefits or services.
Additionally, the University endeavors to provide reasonable accommodations and to ensure equal access to qualified persons with disabilities. Inquiries concerning perceived discrimination or requests for disability accommodations may be referred to the University’s Title IX/ADA/Section 504 Coordinator:

Director, Office of Equal Opportunity and Affirmative Action
201 South Presidents Circle, Rm.135
Salt Lake City, UT, 84112
801-581-8365 (voice/tdd)
801-585-5746 (fax)
www.oeo.utah.edu

I have read and fully understand the above detailed provisions. I understand that by submitting this application electronically, I agree to the same terms that apply to a signed application.

Center for Child Care & Family Resources

Student Affairs

Farmington Health Center - Drop-In Child Care

Child Information & Statement of Understanding