Homes of Hope Childcare Permission & Waiver

Homes of Hope Childcare Permission & Waiver

Complete this form to provide required permissions and emergency information for your child's participation in Homes of Hope childcare activities. (Complete an additional form for more than 3 children.)
The adult training I am participating in
Child 1 Information

Required
Child 1 Full Name

First NameLast Name
Child 1 Date of Birth

MonthDayYear
Date
Medical Information
Does your child have any allergies?
If yes, please list allergies:
Does your child require medication or have any medical conditions?
If yes, please list medications/conditions:
Child 2 Information
Child 2 Full Name

First NameLast Name
Child 2 Date of Birth

MonthDayYear
Date
Medical Information
Does your child have any allergies?
If yes, please list allergies:
Does your child require medication or have any medical conditions?
If yes, please list medications/conditions:
Child 3 Information
Child 3 Full Name

First NameLast Name
Child 3 Date of Birth

MonthDayYear
Date
Medical Information
Does your child have any allergies?
If yes, please list allergies:
Does your child require medication or have any medical conditions?
If yes, please list medications/conditions:
Parent/Guardian Contact
Parent/Guardian Full Name

First NameLast Name
Relationship to Child 1
Relationship to Child 2
Relationship to Child 3
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Parent/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contacts
Emergency Contact(s)
Activity and Transport Permission
I give permission for my child to participate in all scheduled activities and to be transported by Homes of Hope staff or volunteers as needed.
Optional Photo/Media Release
I give permission for my child's image to be used in photos or media by Homes of Hope.
Childcare Release of Liability/Hold Harmless Agreement
Signature
Date

MonthDayYear
Date
Should be Empty:

Homes of Hope Childcare Permission & Waiver

Child 1 Information

Medical Information

Child 2 Information

Medical Information

Child 3 Information

Medical Information

Parent/Guardian Contact

Emergency Contacts

Activity and Transport Permission

Optional Photo/Media Release

Childcare Release of Liability/Hold Harmless Agreement