Childcare Liability Release

Childcare Liability Release
Complete this release to provide childcare details, emergency contacts, and acknowledgement before care begins.
Child Information
Child's Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Allergies, Medical Conditions, or Special Care Instructions
Parent or Guardian Information
Parent or Guardian Full Name
First NameMiddle NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency and Authorized Pickup Details
Emergency Contact Full Name
First NameMiddle NameLast Name
Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pickup Name and Phone Number
First NameMiddle NameLast Name
Childcare Session Details
Childcare Date(s)
MonthDayYear
Date
Start Time
Hour Minutes
AM/PM Option
End Time
Hour Minutes
AM/PM Option
Childcare Location / Site
Liability Release and Acknowledgement
Guardian Signature
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