ShineAtHOTheadStudios Waiver

Child'sName
Date of Birth
Date of Enrollment
Home Phone Number
Home Address
Mother/Guardian Full Name
Home Address
Home Phone
Mobile Phone
E-Mail address
Father/Guardian Full Name
Home Address
Home Phone
Mobile Phone
E-Mail address
Name of person(s) you would authorize to pick up your child if a parent/guardian cannot pick up or be reached.
Name
Relationship to Child
Phone
Name
Relationship to Child
Phone
We require parents to disclose any special needs including allergies, use of EPI Pen, and any other medical condition that would impact your child's safety.
Parent/Guardian Signature Date