Caron Vaping Prevention and Awareness Night-Childcare Form

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Please complete the following form if you are in need of childcare for the Vaping Prevention and Awareness Presentation, we appreciate your assistance in completing the form so we have the necessary childcare in place for this event. Please note that only children between the ages of 3-10 should be included in this coverage. If you have children outside of this age range that may need childcare, please put that in the notes section. We will do our best to accommodate all requests. Childcare begins at 5:45PM and ends at the conclusion of the event (approximately 7:15PM).

Email *

Parent/Guardian Name (Last Name, First Name)

Emergency Contact # (In case we need to get in touch with you during the presentation).

Name of 1st Child (Last Name, First Name, Age)

Name of 2nd Child (Last Name, First Name, Age)

Name of 3rd Child (Last Name, First Name, Age)

Name of 4th Child (Last Name, First Name, Age)

Special Considerations: Medical Needs, Allergies, etc

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

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