Client Information, Registration and Liability Release Contract
DATE_________ Home Phone_________________________
Parent’s Name_________________________________________________
e.mail______________________________ Address__________________________________________City_________________State____Zip____________
Names (children) Date of birth Favorite playtime activities
________________________ ____________ ________________________________________
________________________ ____________ ________________________________________
________________________ ____________ ________________________________________
Any pets?
# Dogs______ # Cats________ Other___________________All current with vaccinations? Yes___ No___
(Please provide copy of current vaccinations on all pets to be kept in our files.)
Have you or any family member living with you ever been convicted of a felony? Yes___ No____
If yes please explain__________________________________________________________________
Mother
Mother- Employer________________________________
Father- Employer________________________________
Mother-Work Phone______________________________
Father-Work Phone______________________________
Mother-Pager/Cell phone__________________________
Father-Pager/Cell phone__________________________
Medical Information
Physician ___________________ Phone____________ Address_________________________________ Hospital ____________________ Phone____________ Address_________________________________ Insurance Carrier_______________________________ Policy #_________________________________
I give consent to A&B Babysitting for the above name child/ren to authorize emergency medical attention if needed.
Parent signature___________________________________________
In case of emergency contact:
(If unable to reach either parent first)
1. ____________________________Phone__________________Relationship___________
2. ___________________________ Phone__________________Relationship___________
Any medical/allergy condition to be considered?_______________
If yes please explain___________________________________________________________________
The undersigned parent/s understands that peace of mind
A&B Babysitting acts only as a service to provide babysitting services. A&B Babysitting are experienced and trustworthy.
If children are sick with colds, flu, chicken pox or other contagious sickness or experiencing special medical conditions, the service must be notified in advance.
An additional $5.00 when 36 hour or less notice is given. Overnight 24 hr service request and/or any requests for a period longer than 8 hour within 24 hours, the payment will be a minimum of $8.00
I, ___________________________________, have read, understand and accept the above conditions of this contract. Client Signature__________________________________Date___________________
DATE_________ Home Phone_________________________
Parent’s Name_________________________________________________
e.mail______________________________ Address__________________________________________City_________________State____Zip____________
Names (children) Date of birth Favorite playtime activities
________________________ ____________ ________________________________________
________________________ ____________ ________________________________________
________________________ ____________ ________________________________________
Any pets?
# Dogs______ # Cats________ Other___________________All current with vaccinations? Yes___ No___
(Please provide copy of current vaccinations on all pets to be kept in our files.)
Have you or any family member living with you ever been convicted of a felony? Yes___ No____
If yes please explain__________________________________________________________________
Mother
Mother- Employer________________________________
Father- Employer________________________________
Mother-Work Phone______________________________
Father-Work Phone______________________________
Mother-Pager/Cell phone__________________________
Father-Pager/Cell phone__________________________
Medical Information
Physician ___________________ Phone____________ Address_________________________________ Hospital ____________________ Phone____________ Address_________________________________ Insurance Carrier_______________________________ Policy #_________________________________
I give consent to A&B Babysitting for the above name child/ren to authorize emergency medical attention if needed.
Parent signature___________________________________________
In case of emergency contact:
(If unable to reach either parent first)
1. ____________________________Phone__________________Relationship___________
2. ___________________________ Phone__________________Relationship___________
Any medical/allergy condition to be considered?_______________
If yes please explain___________________________________________________________________
The undersigned parent/s understands that peace of mind
A&B Babysitting acts only as a service to provide babysitting services. A&B Babysitting are experienced and trustworthy.
If children are sick with colds, flu, chicken pox or other contagious sickness or experiencing special medical conditions, the service must be notified in advance.
An additional $5.00 when 36 hour or less notice is given. Overnight 24 hr service request and/or any requests for a period longer than 8 hour within 24 hours, the payment will be a minimum of $8.00
I, ___________________________________, have read, understand and accept the above conditions of this contract. Client Signature__________________________________Date___________________
