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CHILDCARE REGISTRATION AND LIABILITY WAIVER

I, the undersigned, hereby hold harmless Cornerstone Community Wellness, Inc. and their volunteers, employees and representatives from liability as a result of personal injury or property damage occurring while my child is in their care. I have read and understand the guidelines associated with the childcare services and agree to abide by them. I understand that childcare is only provided while I am present on Cornerstone Community Wellness, Inc. property and that I am ultimately responsible for my child.

April 29, 2024


Please select who will be participating...
Minor
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First Parent's Name

First Name*

Last Name*
First Parent's Age Acknowledgment*
First Parent's Date of Birth*
I certify that I am 18 years of age or older
First Parent's Signature*
Parent'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:*
Minor's Information

Allergies? (please explain)

Notes (include medical conditions or special needs we need to be aware of)
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Parent/Guardian's Phone Numbers

Cell Phone *

Home Phone

Work Phone
Emergency Contact Information

Name *

Relation *

Phone 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*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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