Unaccompanied Child Information & Waiver Form

Unaccompanied Child Information & Waiver Form

Complete the parent/guardian, child and backup contact details, review the drop-off care terms, and provide your signature.
It is our general policy that parents/caregivers remain in the building while children participate in activities, classes, open play, and/or special events. In special cases, we may make arrangements to supervise your child for short periods of time in our open play space or while in a non-adult participation class.

These services are typically provided for an additional fee and require both advance notice and advance payment to make sure we are appropriately staffed. When these services are reserved, parents/legal guardians need to complete and sign this "Unaccompanied Child Information & Waiver Form" to include emergency information for each child left in our care.

Each child left in the care of The Village Playspace LLC will be required to wear a wristband and/or name tag, and must be checked in and signed out with our staff before entering or exiting the space.

The Village Playspace LLC is not legally responsible for the care or supervision of children beyond the end of the class, agreed supervised play timeframe, or close of business. If you have an emergency we will do our best to work with you and contact the appropriate emergency contacts on your list.
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Email Address
example@example.com
Parent/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Marketing Opt-In
SMS/Text Marketing Opt-In
Number of Children Being Dropped Off
Child 1 - Full Name
Child 1 - Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 2 - Full Name
Child 2 - Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 3 - Full Name
Child 3 - Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 4 - Full Name
Child 4 - Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Backup Contact Full Name

First NameLast Name
Backup Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Backup Contact Relationship to Child(ren)
Allergies, Medical Needs, or Anything Staff Should Know
Drop-Off Care Terms

As the parent or legal guardian of the child(ren) listed above, I understand and agree to the following terms as they pertain to drop-off childcare services at The Village Playspace:
1. I will not leave my child in the Childcare Center for longer than three (3) hours. The Village Playspace reserves the right to charge an additional fee if the parent is late for pickup. Additional charges will be incurred at a rate of $50 per half-hour, per child, for any care extended beyond the agreed-upon duration or after the close of business. If we are unable to reach a parent/guardian or any of the emergency contacts for more than 30 minutes past the scheduled pick-up time, the local authorities will be contacted.
2. I will be readily accessible in the event of an emergency or if the caretaker needs to reach a parent or guardian. A backup contact is required when a child is in drop-off care at The Village Playspace.
3. I will help acclimate my child to this new environment until s/he feels secure with the child care attendants. I recognize that all children have good and bad days, and drop-off care may not be in their best interest on certain days.
4. I will not bring my child to The Village Playspace if s/he is ill. This includes having a fever of 99.9°F or higher, a rash, a runny nose, runny eyes, or a cough. The Village Playspace will not administer medication (unless an EpiPen or inhaler or both is required).
5. I will bring any necessary supplies for my child (pacifier, special toy or blanket, etc.).
6. I will not bring my child to The Village Playspace hungry, nor will I bring food/snacks into the play area. Snacks for the children will be provided by the play space. If the child has food allergies, they may bring in a peanut and tree nut free snack.
7. All other terms included in the general waiver shall remain in full force and effect.
Agreement to Drop-Off Care Terms
Parent/Guardian Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State Guidelines & Licensing Notes

The Village Playspace, LLC is an independent, privately-owned business. We are not licensed by the MA Department of Early Education & Care or any other state agency.

Occasional Child Care: According to state guidelines each child may not attend without a parent/guardian in the building more than 4 hours a day and no more than 6 days per month.

Instructional Classes: Unaccompanied children attending classes must be properly registered for the class and retrieved at the end of each class period.

The Village Playspace LLC: 64 Salem Street, Medford, MA 02155
(w) thevillageplayspace.com (p) 781-443-9329 (e) hello@thevillageplayspace.com
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