Brittany Higginbotham Babysitting Intake Form

Babysitting Intake Form

Brittany Higginbotham
Basic Information
Family's Last Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Nearest Cross-streets
Any codes to know for the house? (Alarm codes, garage codes, wifi code, etc.)
Mother/Guardian's Name*

First NameLast Name
Phone Number

Area CodePhone Number
Father/Guardian's Name*

First NameLast Name
Phone Number

Area CodePhone Number
Preferred Contact?*

Mother/Guardian's PhoneFather/Guardian's PhoneEither
Emergency Contact

If unable to reach primary guardians, who should be contacted?
Emergency Contact Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Medical Information

Primary guardians and emergency contact will always be contacted first in case of a medical emergency.
Physician's Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Information
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Add another child?
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Children's Information
Are there infants in the family?*
Child's Name*

First NameLast Name
Favorite Activities*
Any allergies to be aware of?*
If yes, please explain
Any medications taken regularly?
Please list medications and doses
Please briefly describe bedtime (routine, time, favorite stuffed animals, etc.)*
Add another child?
Child's Name

First NameLast Name
Favorite Activities
Any allergies to be aware of?
If yes, please explain
Any medications taken regularly?
Please list medications and doses
Please briefly describe bedtime (routine, time, favorite stuffed animals, etc.)
Child's Name

First NameLast Name
Favorite Activities
If yes, please describe
Any allergies to be aware of?
Any medications taken regularly?
Please list medications and doses
Please briefly describe bedtime (routine, time, favorite stuffed animals, etc.)
Infant Information

(if applicable)
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Child drinks
Formula name/brand
Describe feeding schedule (X oz every Y hours at night, during the day, etc.)
Bottles are preferred

ColdCoolRoom TempWarmVery Warm
Does the child eat solids?
Child can eat the following solids
Typical nap times during the day
Child sleeps on their

BackSideStomachAny
Child uses a sleep sack/swaddle
Child falls asleep best by

PattingSwingingRubbingRockingSingingBouncingOther
Please describe
Favorite play time activities
Any allergies to be aware of?
If yes, please describe
Any medications taken regularly?
Please list medications and doses
Briefly describe bedtime (routine, time, favorite stuffed animals, etc.)
Any notes/special instructions?
Agreement
By sumbitting this contract I/we hereby authorize Brittany Higginbotham to give consent for all emergency medical and/or surgical treatment that may be required for my/our child/children during my/our absence. Brittany Higginbotham 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 while he/she is in child care.
I have read and agree to the above medical consent and release agreement.*

Agree
By sumbitting this form I/we agree to Brittany Higginbotham's booking and cancellation policies. Bookings 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 before the scheduled start time will be subject to a 100% cancellation fee, full hourly payment for all scheduled hours. 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
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Babysitting Intake Form

Basic Information

Emergency Contact

Medical Information

Children's Information

Infant Information

Agreement