Date of Birth*
Emergency Contact 1(Other than Parents)*
Relationship to child*
Please select yes/no to the Following Statements (As Applicable)
CPR / First Aide*
I give permission for my child to receive CPR/First Aide by certified CHAMPS staff. In the event of an emergency I give permission for my child to be transported to and treated by the Winsted Health Center.
I give permission for my child to be transported to CHAMPS Partner loctions via WPS buses. Loctions include Pearson & Batcheller School, Beardsley Library, NW CT YMCA, American Mural Project and WACCC.
My child has permission to be photographed/videotaped for the district website, CHAMPS Facebook page and other publications, including newspaper. I understand my child's name may appear with the photos.
Please give any other information you feel may be helpful in caring for your child.
Please send a confirmation email to the address below: