Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Services agreed upon *

Date Night Nanny

On Call Nanny

Virtual Learning

Children's Transportation Service

Backup Sick Care

Overnight Nanny

Day / Overnight Baby Nurse

Three Day Sleep Consultation Program for Baby / Toddler

On Site Nanny

Family Photo Shoot

Event Nanny

Parent Weekend Retreat

Travel Nanny

Transportation Services *

I require child transportation services (to/from activities such as camp, after school activities, doctor office, etc.)

I will not need child transportation services

Guardian Giving Authorization

First Name

Last Name

Caregiver – ChildcareExpress *

Kaye Taylor

Jay Taylor

ChildcareExpress Team Member

This caregiver shall have the following powers with regard to the above-named children (check all that apply) *

Seek medical care for the children, including but not limited to visits to the doctor and/or hospital

Authorize medical treatment or medical procedures in the event of an emergency

Provide food and shelter for the children and make decisions regarding their day-to-day activities

Transport the children in the caregiver's car, including authorization to pick the children up from school or daycare

Other

Participants Name

WAIVER AND RELEASE OF LIABILITY In consideration of the risk or injury while transporting children to different activities (school, camp, after school activities, doctors office, etc.) I hereby release and forever discharge Childcareexpress LLC. I am voluntarily and entirely at my own risk authorizing Childcareexpress LLC to transport my child(ren). I agree to indemnify and hold harmless Childcareexpress LLC and their representatives against any and all claims. I acknowledge that I have carefully read this "waiver and release" and fully understand that it is a release of liability. In the event of an emergency, please contact the following person(s) in the order presented.

First Name

Last Name

Start of Service *

MM

DD

YYYY

End of Service *

This authorization will terminate on the following date.

MM

DD

YYYY

Electronic Signature *

I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement, I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally.

I have fully read the contract and agree to all the terms & fees as stated above.

Date *

MM

DD

YYYY