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Your Waiver / Intake Form

*This form is an example and does not constitute legal advice. You should consult with a legal professional to create a waiver that meets your specific needs.

Primary Guardian First Name

Last name

Phone

Relation to Child(ren):

Appointed Address:

Emergency Contact(s):

Authorized Pick-Up Persons, if necessary:

Child(ren's) Information

Please list all of medical conditions & preferences. Indicate any serious conditions, allergies, or illnesses (If Any)

Health Goals or Dietary Restrictions

List any developmental concerns (If Any)

What are your children's favorite activities/hobbies?

Parent Acknowledgements & Agreements

I confirm that all information provided is accurate and complete.
I agree to notify staff of any changes in my child’s condition prior to drop-off.
I understand that sick children may not be accepted into care.
I agree to pick up my child promptly at the scheduled time. Late pickup fees may apply.
I understand that childcare services are provided in a group setting.

Liability Waiver & Consent

I give permission for my child(ren) to participate in event childcare services and acknowledge inherent risks.

I acknowledge that while all reasonable precautions will be taken to ensure the safety, I release the provider, staff, and organizers from liability except in cases of gross negligence or misconduct.

I authorize emergency medical care if needed and accept responsibility for any costs.

Photo/Media Release (Optional)

I give permission for my child to be photographed for event or promotional purposes.

Signature

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