LITTLE TOT'S LEARNING DAYCARE, II 1028 Schuman Place Baldwin, NY 11510

Date:

Date

Parent/Legal Guardian Name:

First NameLast Name

Phone Number:

Format: (000) 000-0000.

Email:

example@example.com

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship to the Minor:

Child's Name:

First NameLast Name

Gender:

Date of Birth:

Date

Field Trip & Off-Premises Permission:

I, the Parent/Guardian hereby give Little Tot's Learning daycare, II permission to take my child(ren) off the daycare premises and on excursions that will take place during regular childcare hours. I understand that I may or may not be notified of any such trips beforehand, that trips will be supervised and that all precautions will be made for the safety and well-being of all children.

I, the Parent/Guardian, also understands that Little Tot's Learning Daycare, II will not be liable for any incidents, accidents, or injuries that may occur on or off premises or during daycare hours.

I give my child permission to participate in the following: (Check all that applies)

I give my child permission to participate in the following:

Does the child have any allergies?

Does the child have any medical conditions that you would like to declare?

Any special instructions?

Are there any other activities in which your child should not participate?

Name

First NameLast Name

Parent's Signature

Date Signed

Date

Name

First NameLast Name

Provider's Signature

Date Signed

Date