Plenty TLC Childcare Services — Parents Night Out Waiver & Release Form
For Plenty TLC Childcare Services LLC. Complete all required participant, guardian, emergency, medical, policy acknowledgement, and signature fields. The waiver text for Sections 4–10 will be inserted later.
Participant & Guardian Information
Child's Full Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Child's Age
*
Please Select
3
4
5
6
7
8
Event Date
*
Please Select
August 7 2025
Parent / Guardian Full Name
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address
Is your child fully potty trained?
*
Yes
No
Additional Children
Are you registering more than one child?
*
Yes
No
Child 2 Full Name
Child 2 Date of Birth
-
Month
-
Day
Year
Date
Child 2 Age
Please Select
3
4
5
6
7
8
Child 2 Allergies / Medical Notes
Child 3 Full Name
Child 3 Date of Birth
-
Month
-
Day
Year
Date
Child 3 Age
Please Select
3
4
5
6
7
8
Child 3 Allergies / Medical Notes
Emergency Contact
Emergency Contact Full Name
*
First Name
Last Name
Relationship to Child
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Known Allergies
Medical Conditions Staff Should Be Aware Of
Medications Requiring Administration During the Event
Child's Physician Name & Phone Number
Does your child have an EpiPen or other emergency medication?
Yes
No
Pickup, Security & Impairment Policy
Pickup, Security & Impairment Policy
I agree to the pickup, security, and impairment policy
*
I agree to the pickup, security, and impairment policy
Authorized Pickup Person 1 — Name & Relationship
Authorized Pickup Person 2 — Name & Relationship
Signature & Agreement
Printed Full Name of Parent / Guardian
*
First Name
Last Name
Digital Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: