Childcare Waiver of Liability Child's Name* First Last Birthdate* In Diapers? Yes Permission to use bathroom alone? Yes Allergies?Special NotesDo you have other children you wish to complete waivers for?YesNoSecond ChildChild's Name* First Last Birthdate* In Diapers? Yes Permission to use bathroom alone? Yes Allergies?Special NotesParent/Guardian InformationParent/Guardian Name* First Last Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternate Phone*Driver's License Number*Driver's License State*Emergency Contact* First Last Phone*Relation to Child*I agree to the terms and policies outlined below.* Yes I understand that by checking this box I release and hold harmless Dragonfly Hot Yoga, and its owners, directors, officers, advisors, employees, agents, volunteers, childcare workers, and all other persons or entities acting for them from any liability as a result of personal injury or property damage occurring while the above child/children is/are in their care at Dragonfly Hot Yoga. I understand that childcare services are provided only while I am present in the building and taking class. I understand that childcare services are provided free of charge to monthly members only. All others must pay the set childcare fee. I understand that if my child should become inconsolable during the class session, I am responsible to leave class and attend my child. I have read and understand the Dragonfly Hot Yoga Childcare Policy.