Health History Form Child Care Agreement - Sullivan County Community printable pdf download

Parent Last Name:_______________________ First Name:_________________________ MI:_________

Child Name:__________________________

DOB:____________________ Age:_____________ M / F

Child Name:__________________________

DOB:____________________ Age:_____________ M / F

Child Name:__________________________

DOB:____________________ Age:_____________ M / F

Child Name:__________________________

DOB:____________________ Age:_____________ M / F

Mailing Address:___________________________ City:____________________ State:______ Zip:________

Emergency Contact Name:__________________________ Relationship:_____________________________

Emergency Phone Number:_______ _______ _______

HEALTH HISTORY FORM

Does your child have any limitations, health problems, or food allergies we should be aware of? YES / NO

_________________________________________________________________________________________

CHILD CARE AGREEMENT

I understand that by participating in child care that my child has the right to enjoy all activities associated

with the care and will be subject to all the rules of the SCCH Fitness Center. I understand that a violation of

these rules may result in termination of their enrollment.

All class fees are non-refundable and non-transferable.

I agree to indemnify and hold harmless Sullivan County Community Hospital Fitness Center and their agents

and employees from any liability for any claim, demands, costs, or judgements it or them arising from my

participating in child care. I relinquish all liability towards the SCCH Fitness Center, volunteers and all entities

involved for any injuries or damages that may occur while in child care.

__________________________________________

_______________________________________

Member Signature

Date

__________________________________________

_______________________________________

Fitness Center Staff Member Signature

Date

Health History Form Child Care Agreement - Sullivan County Community