Wiggle Worms Drop In Childcare
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Child's Name And Age *
Siblings attending: (each child must have their own form)
Home Address *
Guardian's Name(s) and Phone Numbers: *
What time will you be dropping off? Event runs 5-7pm. *
Time
:
Do your children have any allergies? *
Please describe all allergies:
Does your child have any medical conditions we should be made aware of or any restrictions for play? *
  Child’s Source of Medical Care/Primary Care Physician’s Name and Phone Number:   
 *
 Preferred Name Of Medical Care Facility/Hospital:    
 *
Please list 3 emergency contacts with relationship and phone number: *
  In case of accident or injury, I authorize any and all emergency medical, dental, and /or surgical care and hospitalization advised by the physicians, surgeon or hospital necessary for the proper health and well-being of my child. 
 *
I have provided information on my child’s special needs (Allergies, Diet, Disabilities, and /or Medical Information) to the provider, as may be necessary to assist the facility in properly caring for my child in case of an emergency.
*
Photo Disclaimer: My child can be photographed for social media *
I agree to not hold Wiggle Worms Playland or Emalee, LLC liable for any injuries incurred while my child attended drop in care. *
$15 fee per child must be paid in advance to hold your spot. Please provide your email address or phone number you would like the pay link sent to. *
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