John Hay Auction Night

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John Hay Auction Night
John Hay Auction Child Care
Saturday, February 11th, 4:30 – 10:00pm
Ages 4-12
Cost:
$45 one child
$55 for two
$65 for three
This includes dinner, snacks and lots of fun. Make checks payable to
the John Hay Foundation.
You must reserve your spot by calling Kids Co. at 206-283-8328.
Please return this form to Kids Co. along with the payment (checks made out to John
Hay Foundation) after you have called to reserve your spot. You must fill out the
attached Consent for Emergency Treatment for each child attending unless
your child is currently enrolled at Kids Co. If your child has any life threatening
allergies please be sure to bring Benadryl and an Epi-pen to give to the Kids Co. staff
the night of the auction.
Child’s Name ____________________________ Age_____
____________________________ Age_____
____________________________ Age_____
Parents/Guardians________________________________________________
Cell Phone Numbers _____________
_______________
Emergency Contacts (someone other than yourself that we can contact during the auction in case of
emergency)
Name____________________________________ Phone____________
Relationship to child_________________________
Name____________________________________ Phone____________
Relationship to child_________________________
Please call if you need to cancel. We always have a wait list and would like to let
families know they have a spot.
CONSENT FOR EMERGENCY TREATMENT
As the parent or legal guardian, I hereby give consent to Kids Co. that my child,
_________________________, may be given emergency treatment to include 1st Aid/CPR by a
qualified staff member of Kids Co. or Medic 1. I also give permission for my child to be transported by
an aid car, ambulance or staff car to the nearest medical treatment center or hospital if necessary. In
the event that I cannot be contacted, I further consent to the medical, dental, surgical and hospital
care, treatment and procedures to be performed for my child by a licensed physician (M.D.), dentist
(D.D.S.), or hospital when deemed immediately necessary or advisable by the physician to safeguard
the life, limb or well-being of my child. It is understood that a conscientious effort will be made to
notify me or other persons listed on this form before such action is taken. The expense of this service
will be accepted by me.
Child’s Physician:______________________________ Telephone:_________________
Address:_________________________________________________________________
Street
City
State
Zip Code
Preferred Hospital:_____________________________ Telephone:_________________
Address:_________________________________________________________________
Street
City
State
Zip Code
Insurance:_____________________________________ Policy #:__________________
Allergies drugs/others)/Reactions:_____________________________________________
Parent/ Guardian Name:__________________________________ Cellular #: __________________
Hm #: __________________
Parent/ Guardian Name:__________________________________ Cellular #: __________________
Hm #: __________________
Parent/Guardian Signature:_________________________________________ Date:__________

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