Fillable MONTGOMERY COUNTY CIRCUIT COURT KIDS SPOT CHILDRENS WAITING (Montgomery County Maryland)

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MONTGOMERY COUNTY CIRCUIT COURT KIDS SPOT CHILDRENS WAITING (Montgomery County Maryland)

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MONTGOMERY COUNTY CIRCUIT COURT
KIDS SPOT CHILDREN’S WAITING ROOM
REGISTRATION FORM
Today’s Date:
Where are you going in the courthouse?
Case Number (if known): Judge/Magistrate’s name (if known):
Parent/Guardian
New Visitor Returning Visitor
Full Name (First and Last) Phone Number
Address City State Zip
ID Verification: Driver’s License Other:
How did you hear about Kids Spot? Courthouse Signage Referral from inside courthouse
Court Website Referral from outside courthouse Other:
Child 1
Child 2
Child3
Full Name (First and Last)
Age
Date of birth
Gender
Allergies (to what)
Medical conditions
If cannot use bathroom without help, please explain.
Special instructions
Race/Ethnicity (optional) – Check all that apply:
White
Black or African American
American Indian/Alaskan Native
Asian
Native Hawaiian and Other Pacific Islander
Two or more races
Some other race
Hispanic, Latino, or Spanish origin
-
MONTGOMERY COUNTY CIRCUIT COURT
KIDS SPOT CHILDREN’S WAITING ROOM
REGISTRATION FORM
IN CASE OF AN EMERGENCY, OR IF I CANNOT PICK-UP MY CHILD, I HEREBY AUTHORIZE THE FOLLOWING PERSON TO PICK-UP MY CHILD:
Name: Phone Number:
Relationship to Child:
I hereby instruct the Montgomery County Circuit Court or any of the agents to take whatever steps may be necessary to obtain or administer
emergency medical care to the benefit of my child(ren) while in attendance at Kids Spot Children’s Waiting Room, and in my absence. These steps
may include, but are not limited to (1) attempt to contact me, (2) call emergency medical personnel. I release the Montgomery County Circuit
Court and its agents from any liability for decisions made in good faith in obtaining or administering such emergency treatments.
I hereby release, waive discharge, and agree not to sue Montgomery County, Maryland, the Court, their officers, agents, or employees from any
and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death,
that may be sustained by my child, or to any property belonging to me or my child, while participating in such activities of the Kids Spot Children’s
Waiting Room, while in, on or upon the premises where the activities are being conducted.
Guardian’s Signature: ____________________________ Printed Name: ____________________________
Date: _______________
In: ___________ Out: ___________ SIGNATURE: _____________________________________
In: ___________ Out: ___________ SIGNATURE: _____________________________________
MONTGOMERY COUNTY CIRCUIT COURT
KIDS SPOT CHILDREN’S WAITING ROOM
PROGRAM POLICIES
1. Kids Spot capacity varies depending on the number of staff and two-year olds present. Children ages 2 to 12 years are able to attend Kids
Spot. If the center is full, you may stay with your child until there is space available. Children in Kids Spot in the morning who must return
for the afternoon due to day-long court proceedings will receive priority space for the afternoon session.
2. Kids Spot is open from 8:00am to 5:00pm, Monday through Friday when the Circuit Court is open for business. Clients must check in 15
minutes prior to any scheduled court event. Kids Spot is closed for lunch from 12:30pm – 1:15pm Monday through Friday when the
Circuit Court is open for business. Children must be picked up at 12:30pm and may not return until 1:15pm.
3. For your child’s safety and protection, the person who signs a child into Kids Spot or the emergency contact must sign the child out of Kids
Spot. A photo ID is required to sign out the child from Kids Spot.
4. If for any reason you need to leave the Circuit Courthouse, you must take your child with you. This includes visits to the District Court
building.
5. Kids Spot staff is unable to give any child medication. However, staff will obtain medical care for your child in case of an emergency.
6. If your child is not picked up by 5:00pm, Kids Spot staff will attempt to locate the guardian. If not located, staff will reach out to the
emergency contact listed on the registration form. If the guardian and emergency contact are not located, Kids Spot staff will contact the
Sheriff’s Office and Court Administration. If necessary, Kids Spot staff will also notify Child Welfare Services of the Department of Social
Services for Montgomery County who may need to retain custody of the child until the guardian is located.
7. If your child appears ill when you arrive, admission will be refused. If your child becomes ill while at Kids Spot, staff will notify you
immediately.
8. If your child cries longer than 20 minutes or does not respect guidelines for safe play, you will be called and asked to return.
9. Kids Spot visitor badges must be visibly worn at all times within the courthouse.
10. Kids Spot is not responsible for any lost or stolen items left at the waiting room. We will do our best to keep all of your child’s items
together during their time at Kids Spot. Please take all valuables with you.
Acknowledgements
I agree to remain at the Circuit courthouse while my child is at Kids Spot Initials: __________
I agree to wear my visitor badge visibly at all times while in the courthouse Initials: __________
I will notify Kids Spot at 240-773-3915 if I change locations within the courthouse during the day
I agree to pick up my child for lunch by 12:30pm
I agree to pick up my child by 5:00pm even if court proceedings are still on-going
I have received a copy of the Kids Spot Guidelines for Guardians
My child may eat the Kids Spot snack
My child has emergency medication with them (yes: _____ no: _____)
noThere are custody issues Kids Spot staff should be aware of (yes: _____
Initials: __________
Initials: __________
Initials: __________
Initials: __________
Initials: __________
Initials: __________
Initials: __________
I have read and understand these policies.
Signature of Parent/Guardian: _____________________________________ Signature of Staff: _____________________________________
Date: _______________
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MONTGOMERY COUNTY CIRCUIT COURT KIDS SPOT CHILDRENS WAITING (Montgomery County Maryland)

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Completed 6 May 2021

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