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Babysitting Release Form
Parent’s Name: _________________________________________________
Child’s Name: __________________________________________________
Address:_______________________________________________________
Phone Number: ________________________________________
Cell Number: __________________________________________
In case of Emergency Contact: ____________________________________
Emergency Contact Number: ______________________________________
Allergies, physical ailments, any abnormalities we should be aware of, etc:
_________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
I hereby accept any and all responsibility for and assume the risk of any and all injury or
damage to my person or dependent children which might arise directly or indirectly as a
result of, and a participation in the Academy Babysitting program. I hereby expressly
release discharge and hold harmless from any liability whatsoever the Academy and all
employees in their capacities as representatives of the Academy. I certify I am familiar
with the contents of this release. I have read and understand and it is my intention that by
signing this that the same be binding on me and my heirs, administrators, executors and
assignees.
_________________________________________ _______________
Signed by parent or legal guardian Date