Saint Ambrose Childcare Ministry

Created to help be a blessing for moms, dads, and caregivers in our Parish!

This ministry gives parents/guardians a chance to grow in their faith by providing childcare right on the Saint Ambrose Parish campus during various parish small groups, couples events, speakers and more!

Individuals who are members of this ministry are over the age of 18, VIRTUS trained, and hold a current background check.

Contact Geneva Chrysanthus at 330.460.7338 or CGhrysanthus@StAmbrose.us for more details!

Interested in utilizing this ministry? Please fill out BOTH forms below.

Childcare Acknowledgement Form

Child's Name(Required)

First Last

Primary Parent/Guardian Name(Required)

First Last

Relationship to Child(Required)

Email(Required)

Phone(Required)

I understand that the Saint Ambrose Childcare Program is a Ministry that operates with the help of VIRTUS trained and background checked volunteers. I understand that this service is only available on the parish campus and that I must remain on the parish campus while my child(ren) is with the childcare worker(s).(Required)

I agree to the childcare policy.

Please type your FULL NAME and DATE.(Required)

By typing your name, you are signing this authorization form.

CAPTCHA

Childcare Program Emergency Contact & Authorization Form

Child's Information

Name(Required)

First Last

Birth Date(Required)

Month

Day

Year

Age(Required)

Gender(Required)

Male

Female

Current Grade Level(Required)

Type N/A if not applicable.

Child's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent(s) / Guardian(s) Information

Primary Parent/Guardian Name(Required)

First Last

Relationship to Child(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Home Phone

Email(Required)

Place of Work & Department(Required)

Work Phone

Work Email

Is there a secondary parent/guardian you wish to list?(Required)

Yes

Secondary Parent/Guardian Name(Required)

First Last

Relationship to Child(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Home Phone

Place of Work & Department(Required)

Work Phone

Work Email

Emergency Contact Information (other than parent/guardian)

Name(Required)

First Last

Relationship to Child(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Home Phone

Email(Required)

Place of Work & Department(Required)

Work Phone

Work Email

I authorize this person to pick up my child in case of Emergency:(Required)

Yes

Child's Medical Information

Child's Primary Doctor(Required)

Phone Number of Doctor's Office(Required)

Known Allergies(Required)

Enter "NONE" if not applicable.

Known Medical Conditions(Required)

Enter "NONE" if not applicable.

Regular Medications(Required)

Enter "NONE" if not applicable.

Special Notes

Medical Consent

I authorize the staff of Saint Ambrose to administer FIRST AID procedures to the above listed child, when necessary.(Required)

I consent.

I give consent for the above listed child to be transported to receive EMERGENCY MEDICAL CARE, if necessary. I understand that I will be responsbile for any charges that are not covered by my child's insurance.(Required)

I consent.

I refuse.

I do NOT give my consent for EMERGENCY MEDICAL CARE for my child. In the event illness or emergency treatment is required, I wish the program childcare worker to take no action or the action listed below.(Required)

I agree.

Preferred Action in Emergency Situation involving the above child.(Required)

Please type your FULL NAME and DATE(Required)

By typing your name, you are signing this authorization form.

Bathroom Assistance & Diaper Change Consent

I consent for the above listed child to have their diaper changed and/or given bathroom assistance, if necessary. I understand that this is only as needed.(Required)

I consent.

I refuse.

I do NOT give my consent for bathroom assistance and/or diaper changing of my child. In the event of bathroom assistance and/or diaper changing is required, I wish the childcare worker to call or text the parent/guardian at the number listed below.(Required)

I agree.

Preferred Phone Number to call for bathroom assistance and/or diaper changing:(Required)

Please type your FULL NAME and DATE(Required)

By typing your name, you are signing this authorization form.

Photo Release Authorization Consent

I (we) the parent(s) and/or guardian(s) of the above listed minor child do hereby consent and authorize the release, publication, dissemination, distribution, use and/or reproduction of any and all photographs taken of my (our) daughter/son during her/his participation at Saint Ambrose programs by an employee, agent or representative of Saint Ambrose or independent contractor. This RELEASE AND AUTHORIZATION acknowledges that all photographic negatives, positives, and prints shall constitute the property of Saint Ambrose and may be used by Saint Ambrose for any purpose determined at its discretion without further notice or any compensation to me or my daughter/son.(Required)

I consent.

I refuse.

Please type your FULL NAME and DATE(Required)

By typing your name, you are signing this authorization form.

CAPTCHA

Saint Ambrose Childcare Ministry

Created to help be a blessing for moms, dads, and caregivers in our Parish!

Childcare Acknowledgement Form

Childcare Program Emergency Contact & Authorization Form

Child's Information

Parent(s) / Guardian(s) Information

Emergency Contact Information (other than parent/guardian)

Child's Medical Information

Medical Consent

Bathroom Assistance & Diaper Change Consent

Photo Release Authorization Consent

Title

Parish Registration

Eucharistic Adoration