Caregiver Information Form
(confidential)
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Email *
HOUSEHOLD INFORMATION
Family Surname *
Home Address (Full Street Address, City, State ZIP code) *
Preferred contact person (for general communication - information, questions, event registrations, etc) *
Would you like to join our Caregiver email list for notice about upcoming programs, events, and registration? (You can also sign up directly at https://www.kidsatheartco.org/sign-up/)
 *
CAREGIVER #1 INFORMATION
Caregiver #1 Name (First and Last) *
Email address *
Cell phone number *
Date of Birth *
MM
/
DD
/
YYYY
Spanish Speaking *
Caregiver #1 Ethnicity *
Caregiver #1 Race (check all that apply) *
Required
CAREGIVER #2 INFORMATION
Please complete as much of this section as is applicable.
Caregiver #2 Name (First and Last)
Email address
Cell phone number
Date of Birth
MM
/
DD
/
YYYY
Spanish Speaking?
Clear selection
Caregiver #2 Ethnicity
Caregiver #2 Race (check all that apply)
EMERGENCY CONTACT INFO
Please update Kids at Heart staff if any emergency contact information changes after completing this form.
Emergency Contact Name (First and Last) *
Cell phone number *
Doctor's Name
Doctor's Phone Number
Health Insurance Company
PERMISSIONS, WAIVERS, & AGREEMENTS
Please read and agree to the items below regarding your child's participation in Kids at Heart events.
Functions and Activities - It is my understanding that participating in the programs, recreation and other activities of Kids at Heart at any of the locations is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. *
Required
Release of Liability - By signing this Permission/Waiver Form, I expressly warrant that the children under my parent/guardianship are capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the children or me participating in the activities, whether such risks are known or unknown to me at this time. I further release Kids at Heart and its leaders, employees, volunteers, and agents from any claim that my children may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against Kids at Heart or its leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless Kids at Heart and its leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my children during such activities. *
Required
First Aid and Emergency Medical Treatment - I recognize that there may be occasions where the children under my parent/guardianship or I, if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of Kids at Heart to seek and secure any needed medical attention or treatment for the children under my parent/guardianship or me, if I am a participant, including hospitalization, if in the agent's opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment. *
Required
I represent that I am the parent/guardian of the children attending Kids at Heart events, who are under 18 years of age. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof. *
Required
I give permission for the children under my parent/guardianship to participate in the activities of Kids at Heart, including any special events/activities described above. In consideration for allowing the participation of the children in the activities of Kids at Heart, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of all listed children, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns. *
Required
Signature of Legal Guardian / Parent / Foster Parent (Type your first & last name) *
Date *
MM
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DD
/
YYYY
KIDS AT HEART CAREGIVER INFORMATION FORM
Last updated 09/2022.
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