Childcare Service Waiver and Release Form

Parent/Guardian Information

Full Name: Address: Phone Number: Email Address:

Child Information

Child's Full Name: Date of Birth: Allergies/Medical Conditions:

Emergency Contact

Emergency Contact Name: Emergency Contact Phone:

Waiver and Release

I, the undersigned, understand and agree to release, indemnify, and hold harmless the childcare provider and its staff from any and all liability for injuries, loss, or damages to my child or family which may occur during or as a result of participation in the provided childcare services.

Parent/Guardian Signature: Date: