Parent/Guardian Consent Waiver | Life Moments Child Care

PARENT/GUARDIAN INFORMATION

Onsite Parent/Guardian Full Name:

Onsite Parent/Guardian Phone:

Emergency Contact:

COMPLETE 1 (ONE) FORM FOR EACH CHILD

Child's First Name

Child's Last Name

Child's Age

Allergies/Medical Condition(s):

Special Instructions:

I certify that I have disclosed all medical conditions, allergies, behavioral concerns, and special needs.

CONSENT FOR PARTICIPATION

I give permission for my child to participate in Life Moments Childcare services:

Yes

No

I understand these services are temporary, event-based, and not licensed under North Carolina law.

Yes

No

PICK-UP AUTHORIZATION

Full Name of individual(s) authorized to pick up your child (Valid photo ID may be required):

EMERGENCY AUTHORIZATION

I authorize Life Moments Child Care staff to provide basic first aid within the scope of their training.

I authorize Life Moments Child Care staff to contact emergency medical services (911).

I authorize Life Moments Child Care staff to arrange transportation for emergency car if necessary.

If I cannot be reached, I authorize licensed medical professionals to provide necessary emergency treatment to my child.

ACKNOWLEDGMENT

I understand that every reasonable effort will be made to contact me immediately in the event of an emergency

INSURANCE INFORMATION (OPTIONAL)

Insurance Provide:

Policy Number:

PARENT RESPONSIBILITY

I agree to remain on-site or immediately reachable during the event and to respond promptly if contacted.

I certify that I have fully disclosed all medical conditions, allergies, behavioral concerns, and pertinent special needs to Life Moments Child Care.

I declare that the info I’ve provided is accurate and complete.

Photography Release (Optional)

I grant permission for Life Moments Child Care to take non-identifying photos of activities for promotional use (website/social media).

LIABILITY WAIVER

To the fullest extent permitted under North Carolina law, I release and hold harmless Life Moments Child Care, its owners, employees, and contractors from any claims, liabilities, or damages arising from participation, except. incases of gross negligence or willful misconduct.

ASSUMPTION OF RISK

I acknowledge that participation in group childcare activities involves inherent risks, including but not limited to minor injuries from play. By signing this agreement, I voluntarily assume all such risks and agree that Life Moments Child Care shall not be held liable except in cases of gross engligence.

Signature

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Wavier & Consent