Mommy Beauty Cutie Foundations

Name of first child*

First NameLast Name

Name of second child

First NameLast Name

Please indicate your gender of child 1*

MaleFemale

Please indicate your gender of child 2

MaleFemale

Date of birth of child 1*

Date

Date of birth of child 2

Date

Special Conditions/ Allergies and Behaviors*

Disabilities, chronic illnesses etc. (if any)

Is your Child Potty-trained or in Diapers? Please answer for all children*

If in diapers or pull ups please provide those and a change of clothes

Additional Information we need to know about your child?*

Please let us know what kind is childcare support you need ( SELECT ONE ONLY )

Pop up site care~Mommy Concierge’s are available at our pop-up site located at the Homewood library on scheduled days. This location provides a welcoming space for children to engage in community activities while receiving additional childcare support MUST BE SCHUEDLE IN ADVANCE. We will contact youDoctors Appointment Assistance: A Mommy Concierge can accompany you to your medical appointments, providing support in the waiting room and ensuring your child feels comfortable while you attend to your appointment. ( This is for any schedule appointments you have. We will call you to arrange.Mental Health Break or Job interviewPost partum recovery break ( This is great for a mom that has recently had a baby and would like time to rest. Or would a mom of multiple and would like time to with their newborn while other children are away at the pop up event.

Parent Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Parent email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact and person allowed to pick up *

First NameLast Name

Phone Number*

Please enter a valid phone number.

To ensure the safety and security of all mothers and concierges, we require a photo ID for service access. Please upload your photo ID ( The person requesting must be the person on the ID) *

Photographic Release grant permission for Mommy and Me Haven to use photographs of my child for promotional purposes.*

YesNo

We will contact you to schedule services. Remember we schedule services in the order we received them.

We kindly ask that you provide all necessary items for your child’s care during their time with us. This includes diapers, wipes, and a change of clothes. If your child is in pull-ups, please ensure that those are also included.

Additionally, for infants still on formula, we require that bottles be pre-made and mixed prior to your visit, the Mommy Concierges, are unable to prepare bottles on-site.

We also encourage you to include any additional snacks, toys, and your child's feeding schedule to help us cater to their needs.

Please note that we do not administer any medications. Thank you for your cooperation in ensuring a comfortable and enjoyable experience for your child.

Disclaimer/ Agreement and Liability Waiver for Emergency Childcare Services

Thank you for considering our emergency childcare services. Please be advised that all requests are subject to availability, and we cannot guarantee that every request will be fulfilled. To facilitate a smooth process, we kindly ask that you provide detailed information when submitting your request.

Please note that our services do not include watching children inside their homes, and we do not provide transportation. It is the responsibility of parents to drop off and pick up their children at our designated locations.

Keep in mind that our pop-up sites can only accommodate up to four children at their respective locations, and we may not be able to take on multiple children from the same family.

Timely pick-up is essential; please arrive at the agreed-upon time. By signing this form, you acknowledge and agree to a late fee of $20 for every 20 minutes that a Mommy Concierge must wait for you to arrive and pick up. Additionally, failure to pay these late fees may result in restrictions on your ability to utilize our services in the future. We may also seek other legal actions to recieve fees occured.

As the child's parent/guardian, by signing this field I agree to be responsible for all the charges which are excluded from health insurance in an emergency situation. If my child has no health insurance, I also agree to be responsible of all the charges about my child's health.

Acknowledgment of Risks

I, the undersigned parent/guardian, acknowledge that participating in childcare services with Mommy and Me Haven involves inherent risks, including but not limited to accidents, injuries, or illnesses.

Assumption of Responsibility
I assume all responsibility for any injuries, accidents, or illnesses that may occur while my child is in care.

Indemnification
I agree to indemnify and hold harmless Mommy and Me Haven and its affiliates from any claims, losses, or expenses arising from my child's participation in the program.

Emergency Medical Authorization
In case of emergency, I authorize Mommy and me Haven to seek medical attention for my child at my expense.

Disclosure of Medical Conditions
I have disclosed any relevant medical conditions or allergies that may affect my child's participation.

Thank you for your understanding and cooperation. We look forward to assisting you with your childcare needs.

Parent Signature*

Mommy and Me Haven LLC