Hive Care Enrollment Forms

Child's Name*

First NameLast Name

Birth Date*

Date

Gender

Primary Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Mailing Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Area CodePhone Number

Parent/Guardian Name*

First NameLast Name

Email Address*

example@example.com

Cell Phone Number*

Area CodePhone Number

Parent/Guardian Residential Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Typical Location of parent/guardian during drop-off programs?*

Parent/Guardian Name

First NameLast Name

Email Address

example@example.com

Cell Phone Number

Area CodePhone Number

Parent/Guardian Residential Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Typical Location of parent/guardian during drop off?

Emergency Contacts and Authorized Pick-ups

Your child will only be released to parent/guardians, emergency contacts or individuals with written permission. ID's will be checked at first pick up meeting (This includes first pick up by parent/guardian if the parent/guardian has not previously been met).

Emergency Contact 1*

First NameLast Name

Relationship to child*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 2*

First NameLast Name

Relationship to child*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list any individual who may pick up your child from Anie's Hive. Please let Stephanie Buzzell know if you would like to add pick up contacts at any time.

First NameLast Name

Do you have any custody or restraining order documents that may be necessary for the care and dismissal of your child? If yes, please bring a copy with you on your first day of drop-off care.

YesNo

Medical Information

Physician Name

First NameLast Name

Phone Number

Area CodePhone Number

Preferred Hospital

Insurance/Health Coverage (Company)

Policy Number

Please list any Allergies (food and/or medication) or note none*

Please list any dietary restrictions, sensitivities, lifestyle choices or preferences or note none.*

Please list any of the following: Current medications, Chronic health concerns, behavioral considerations or note none.*

Please note any other vital information you think we may need to know to care for your child.

I, First Name* Last Name*, give Stephanie and Michael Buzzell permission to administer basic first aid and/or CPR to my child, First Name* Last Name*, and/or take my child to a hospital for medical treatment when I cannot be reached or when delay would be dangerous to my child's health. I also give permission for Stephanie and Michael Buzzell to use their sole discretion in the event emergency first responders are deemed necessary and delay is believed to be dangerous to my child's health. I understand I am financially responsible for any emergency care charges and/or all treatment charges incurred by participation in Hive membership, programs and activities.

Signature*

Date*

Date

Please note any further instructions for emergency care/first responders:

Permissions and releases granted (or denied) will be reviewed by Anie's Hive for membership, program and activity participation in order to provide apporpriate care and participation options for your child/family.

I, First Name* Last Name*, give permission for my child, First Name* Last Name*, to participate in Anie's Hive membership, programs and activities. I further give permission for Stephanie and/or Michael Buzzell to care for my child on Anie's Hive premises as part of Hive membership, programs and activities. As a member of Anie's Hive I understand it is my responsibility as the parent/guardian to discuss ratios/supervision policies and will only participate in the programs that are right for our family.

Each checked box below indicates I give my child permission for the listed activity.

Engage in nature play (and I understand the inherent risks of nature play as outlined in Anie's Hive policies)Play BarefootPlay outdoors in (safe) layers of choicePlay outdoors without direct supervision (age 6+)Interact with Hive animals (I understand the risk associated with any animal interactions as outlined in Anie's Hive's policies)Participate in culinary activitiesEnjoy Hive offered food and drink (as appropriate based on dietary needs and allergies)

I understand my child needs to arrive with:*

Food for hours of care (snacks and lunch as needed)Appropriate layers for DAILY outdoor play (Shoes/boots required for winter play. Snow pants strongly encouraged especially on snowy/frigid days)Change of clothes (in case of spills, messes, accidents, etc.)Any medication necessary to provide appropriate care for your child (epi-pens, Benadryl, etc) and written administration instructionsAny sunscreen, bug spray, topical ointments, diapers, wipes, etc. your child may need while in care.

By checking the boxes below, I indicate I have read and understand:*

I am responsible for the timely pick up of my child at program end as outlined in Anie's Hive policies. I further understand failure to pick up my child at program end (or previously arranged extended hour time agreement) may result in accrued fees as outlined or removal of Anie's Hive membership.Anie's Hive health and wellness policies. There are risks (and benefits!) of Hive membership, programs, and activities and community and nature play. I understand I am solely responsible for the well-being of my family and will refrain from Hive community attendance if at any point I feel it is not best for my family/child. I will respect the personal decisions of other Hive members.

I, First Name* Last Name*, certify I am the legal parent/guardian of First Name* Last Name* and as such voluntarily enroll for permission for my child to participate in Hive membership drop-off programs and activities. I understand that there are risks associated with participation in Hive membership, programs, and activities, such as physical and/or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, death or economic loss. These injuries or outcomes may arise from our own or other's actions, inactions or negligence or the condition of activity location or facilities. Nonetheless, I assume all risks of participation in Hive membership, programs and activities, whether known or unknown to me. In consideration for being allowed to participate in Hive member drop-off programs and activities, I release Stephanie Buzzell, Michael Buzzell, Anie's Hive, their employees, volunteers and associates from any and all liability associated with participation in Hive membership, programs, and activities. I agree to hold harmless from any and all claims, loss or damage to our personal property, liabilities and costs, including attorney fees, as a result of our participation and membership.

Signature*

Date*

Date