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Emergency Contact Form & Waiver of Liability 

  • I/we authorize Whimsy Willow, Inc. to obtain emergency medical care for my/our child. Any expenses incurred in obtaining such medical care will be paid by me/us.
  • I/we give permission for my/our child to be transported out of Whimsy Willow, Inc. in case of emergency.
  • I/we give permission for my/our child to participate in all camp/after school/drop-off activities. I/we understand that participation in the Activity may also include visits to a nearby park with play structures as well as fieldtrips to nearby locations such as the library or movie theater.  
  • I/we understand that no credit is given for partial attendance. No portion of the tuition will be refunded if the child is absent, withdrawn, suspended, or should otherwise fail to complete the Activity.
  • I/we give Whimsy Willow, Inc. the absolute rights and permission to publish and/or copyright photographs taken of my child during the Activity. These photographs may be used for the following purposes: website, marketing materials, books, and other publications of Whimsy Willow, Inc. Photographs may be used without compensation to me/us or my/our child, and I/we hereby waive any right to inspect or approve the finished product, including written copy, that may be created in connection therewith, or the use to which it may be applied.
  • I/we do hereby release, waive, discharge, and covenant not to sue Whimsy Willow, inc., its officers, employees, and agents for liability from any and all claims including the negligence of Whimsy Willow Inc., its officers, employees and agents, resulting in personal injury, accidents or illnesses, including death, and property loss arising from, but not limited to, participation in the Activity.

Today's Date: February 25, 2026


First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Insurance
Insurance Carrier*
Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Activity
Day Camp
Drop Off
After School Program
Other
Date(s):

Child Information

Grade:
School:
If other, please list:
Parent/Guardian Name *
Parent/Guardian Phone Number *
Second Parent/Guardian Name
Second Parent/Guardian Phone Number

Other Emergency Contacts (relatives or friends authorized to pick up child if parent cannot be reached)

Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information

Name of Doctor:
Phone:
Name of Dentist:
Phone:

Information we should know about your child such as medical problems; medication(s) being taken; allergies to foods, bee stings, poison oak, etc; extreme fears; or anything else you feel we should know:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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