Childcare Provider Access Form

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Email *

Name of family making request: *

Childcare Provider

First Name: *

Last Name: *

Childcare provider's email: *

Childcare provider's birthdate: *

YYYY

Childcare provider's address: *

City: *

Zip *

Number of children under the care of the childcare provider. *

Approximate frequency per week of supervision at the Club. *

Childcare Provider Policy:

Childcare Provider must remain with the children supervised.
Childcare Provider must submit a recent picture of herself at check-in
Childcare Provider pays the guest fee when at the club with the parent.
Childcare Provider does not have the privilege to bring in guests.
Childcare Provider entry to club is limited to their role or as a guest.
Childcare Provider is not covered by the club’s insurance carrier.
Childcare Provider must follow the club rules and club polices.
Failure to follow the Childcare Policy results in a warning and a $25 fine.
The second time the privilege for the provider and/or family is revoked.

Signatures Required:

Family making the request: *

Childcare provider: *

A copy of your responses will be emailed to the address you provided.

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