Date Night

Date *

- Month - Day Year

Start Time *

: Hour Minutes

Date *

- Month - Day Year

End Time *

: Hour Minutes

Family's Last Name *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Nearest Cross-Streets

Are there any infants in the family? *

Child's Name *

First Name Last Name

Date of Birth *

/ Month / Day Year

Favorite Activities

Allegies to be aware of? *

If so, please explain:

Medications taken regularly? *

If so, please explain:

Please briefly describe bedtime and other important routines *

Add another child?

Child's Name *

First Name Last Name

Date of Birth *

/ Month / Day Year

Favorite Activities

Allegies to be aware of? *

If so, please explain:

Medications taken regularly? *

If so, please explain:

Please briefly describe bedtime and other important routines *

Child's Name *

First Name Last Name

Date of Birth *

/ Month / Day Year

Favorite Activities

Allegies to be aware of? *

If so, please explain:

Medications taken regularly? *

If so, please explain:

Please briefly describe bedtime and other important routines *

Child's Name *

First Name Last Name

Date of Birth *

/ Month / Day Year

Favorite Activities

Allegies to be aware of? *

If so, please explain:

Medications taken regularly? *

If so, please explain:

Please briefly describe bedtime and other important routines *

Are any of the children sick? *

If so, who, and for how long?

Guardian 1 Name *

First Name Last Name

Phone Number *

- Area Code Phone Number

Addt'l. Phone Number

- Area Code Phone Number

Guardian 2 Name

First Name Last Name

Phone Number

- Area Code Phone Number

Addt'l. Phone Number

- Area Code Phone Number

Preferred Contact? *

Guardian 1 Phone Guardian 2 Phone Either

Emergency Contact Name *

First Name Last Name

Relationship *

Phone Number *

- Area Code Phone Number

Physician's Name

Phone Number

- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Insurance Information

I/we agree to have Paisley Bedford Parker take photos of my/our child/children during my/our absence. I/we acknowledge that the photos will not be posted to any form of social media with identifying factors, real names, or locations. Specific permission must be granted for photos to be posted otherwise. I/we acknowledge that photos are taken specifically for professional use; for updates to listed guardians and/or to documents activities for portfolio/website. *

Agree Do Not Agree

By submitting this contract I/we hereby authorize Paisley Bedford Parker to give consent for all emergency medical and/or surgical treatment that may be required for my/our child/children during my/our absence. Paisley Bedford Parker agrees to make attempts to contact both legal guardians and the listed emergency contact should a medical emergency arise. I/we understand that I/we assume all financial responsibility for any treatment of injuries sustained to my/our child/children while he/she is in child care.

I have read and agree to the above medical consent and release agreement. *

Agree

By submitting this form I/we agree to Paisley Bedford Parker's booking and cancellation policies. Booking must be made for a minimum of four hours. Bookings cancelled within 48 hours of the scheduled start time will be subject to a 50% cancellation fee, full hourly payment for half the scheduled hours. Bookings cancelled within 24 hours of the scheduled start time will be subject to a 100% cancellation fee, full hourly payment for all scheduled hours. If booking is cancelled by Paisley Bedford Parker within 48 hours of a scheduled start time, parents are entitled to one free hour of services to be used within 60 days. If booking is cancelled by Paisley Bedford Parker within 24 hours of a scheduled start time, parents are entitled to two free hours of services to be used within 60 days. Exceptions are made for circumstances out of both parties' control; death in the family, extreme weather, or sudden illness or injury. In these situations neither party is held responsible for cancellation fees/services.

I have read and agree to the above booking and cancellation policy. *

Agree

My signature below affirms that I have read and agree to both the medical consent and release agreement, and the booking and cancellation policy.

Signature *

Clear

Date *

/ Month / Day Year

How would you like to recieve confirmation? *

Text Call Email

Phone Number *

- Area Code Phone Number

E-mail *

Date Night Intake Form

Date Night Request

Basic Information

Children's Information

Contact Information

Emergency Contact

Medical Information

Agreement