The Organize Cbus Collective is dedicated providing an organizing space for students and community members throughout Ohio, especially women, people of color, queer, and working-class people. To this end we recognize the importance of trustworthy and accountable childcare services. Parenthood should NOT be a barrier to liberation!
If you're planning on coming to the conference and need somewhere for your young revolutionary to kick-it while you're in workshops please fill out the below registration form (thanks RNC Welcoming Committee) and email it back to us at: organizecbus@googlegroups.com
Deadline for registering for childcare is Monday, May 11th. This is so that we can make sure we'll have enough people, games, toys, etc to responsibly look after everyone.
brat-block love!
Organize Cbus Collective
Childcare Registration Form
Parent/ Guardian Name: __________________________________________________
Parent/ Guardian Address: ________________________________________________
_______________________________________________________________________
Parent/ Guardian Phone Number(s): ________________________________________
Emergency Contacts, Name(s) & Number(s) (others who may pick up you child, list as many as
you need to so that we will absolutely be able to contact someone who can take responsibility for
you child): ______________________________________________________________
________________________________________________________________________
________________________________________________________________________
Name of Child: __________________________________________________________
Date of Birth: _____________________________
Medical Information:
Physician: ________________________________________________________
Insurance Info: ___________________________________________________
Medications: _____________________________________________________
Medication Instructions: ___________________________________________
Allergies: _______________________________________________________________
Food Preferences/ Restrictions: ____________________________________________
Potty Trained? __________________________________________________________
Please list on the back of this form (or below if you’re using a computer) any information that
will help us better care for your child, such as: likes, dislikes, favorite activities…
Authorization for Emergency Medical Treatment:
By signing this agreement, the parent/ guardian affirms that he/ she is the person
authorized to enter into this agreement, and authorizes the childcare volunteer on duty to seek and obtain emergency medical treatment for my child if circumstances appear to warrant such
treatment. The parent/ guardian agree to reimburse the person or persons who obtain such
emergency medical treatment for any expense reasonably incurred. The parent/ guardian agree to indemnify the person or persons who obtain such emergency medical treatment from any and all claims for payment by medical services providers arising from the incurring of reasonable
medical expenses.
_____________________________________________________________
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