Online Registration Form

Registration Form

Hey there time saver ;)

Thank you for filling this out early!

Parent/Guardian:

Parent/Guardian's First Name

Home Address

Parent/Guardian's Last Name

City

State

Zip Code

Cell Phone

Home Phone

Work Phone

Employer's Full Address

Parent/Guardian:

Parent/Guardian's First Name

Home Address

State

Zip Code

Parent/Guardian's Last Name

City

Cell Phone

Home Phone

Work Phone

Employer's Full Address

Child Information

Child #1: First Name

Gender (M/F)

Child #1: Last Name

Date of Birth

Are there any special conditions to be aware of (medical/allergy/dietary/asthma/special needs)?

Child #2: First Name

Gender (M/F)

Child #2: Last Name

Date of Birth

Are there any special conditions to be aware of (medical/allergy/dietary/asthma/special needs)?

Child #3: First Name

Gender (M/F)

Child #3: Last Name

Date of Birth

Are there any special conditions to be aware of (medical /allergy /dietary /asthma /special needs)?

Child #4: First Name

Gender (M/F)

Child #4: Last Name

Date of Birth

Are there any special conditions to be aware of (medical /allergy /dietary /asthma /special needs)?

Persons Allowed to Pick Up & Emergency Contacts

In addition to Parents/Guardians listed previously, I authorize Muletown Kids to release my child and leave the facility with the following persons only:

(IMPORTANT: It is a requirement to list one person besides a parent/guardian)

First & Last Name

Relationship to the Child

Phone Number

First & Last Name

Relationship to the Child

Phone Number

First & Last Name

Relationship to the Child

Phone Number

*Please notify us ahead of time for pick ups other than parent/guardian. We require a Photo ID for all pick ups.*

Emergency Information

In the event I cannot be reached to make arrangements for emergency medical attention at the time of illness or accident. I authorize Muletown Kids to have my child transported to: (If no preferred medical facility is listed, child will automatically be transported to Maury Regional Hospital.)

Name of Physician

Physician Address

Phone Number

Name of Hospital

Hospital Address

Phone Number

Consent for Medical Treatment

I give consent for Muletown Kids to secure any and all necessary emergency medical care for my child. I certify my child is in excellent health, physical condition and has no medical psychological, physical or mental condition which has not been disclosed to Muletown Kids on this registration form.

Parent/Guardian Signature

Date

Waiver of Liability

Waiver. In consideration for my child's acceptance and participation and intending to be legally bound, I agree that: I and my child voluntarily assume all risks associated with my child's use of daycare services; I understand that Muletown Kids (hereinafter "Releasee") does not assume any responsibility for any Injuries and Damages arising from or connected with my child's use of daycare services; I understand that using the daycare service of negligence or otherwise, from natural causes, physical conditions, recreational activities.

Indemnification and Hold Harmless. This is a legally binding agreement. I understand that by signing this Waiver of Liability, I release, indemnify and hold harmless Releasee and its owners, directors, officers, advisors, employees, agents, and all other persons or entities acting for them from any and all claims, demand, suits, cost and charges, including attorney's fees, in connection with or arising out of daycare services, including but not limited to: personal injury, bodily harm, injury, property damage occurring while the child/children is/are on the property of Releasee, or any derivative claims I may have.

Policy Agreement. I agree without reservation that I must explain to my child the rules of the Releasee. I hereby agree that my child agrees to accept and abide by the rules and policies of Releasee and to obey the direction of Releasee's representatives.

Acknowledgement of Understanding. With my full understanding of the above information, I agree to assume any and all risk associated with sending my child to Releasee for daycare services. I acknowledge that I am signing the agreement freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability to the greatest extend allowed by law.

Severability. The undersigned further expressly agrees that the foregoing Waiver, Indemnification and Hold Harmless, Policy Agreement, and Acknowledgement of Understanding are intended to be as broad and inclusive as is permitted by the law of the State of Tennessee and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Type Your Full Name

Your Signature

Date

Name(s) of Minor Child(ren)

Pictures/Videos

We regularly take and share pictures or videos on our website, marketing material and social media. Why do we want to share these? It shows the children having fun at Muletown Kids, making friends, participating in arts and crafts etc. If there is an issue with this, please ask for a refusal sheet, so that we can attach it to your file.

**I understand that this facility is not required to be licensed by the state as a child care agency.** We are registered and monitored by the State of Tennessee.

Parent/Guardian Signature

Date

I understand that there is a $5 registration fee that will be applied to the total of my first visit.

Thanks for registering!