Childcare Program Waiver Form
Please complete this form to provide consent and important information for your child's participation in our childcare program.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Emergency Contact Name (other than parent/guardian)
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
List any allergies, medical conditions, or medications for the child
Authorized Persons for Pickup (other than parent/guardian)
Additional Information or Special Instructions
Parent/Guardian Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit Waiver
Submit Waiver
Should be Empty: