Parent / Guardian Information

Guardian First Name *

Guardian Last Name *

Guardian Phone *

Guardian Email we have on file *

Guardian 2 Full Name (optional)

Guardian 2 Phone Number (optional)

Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship to Child

Emergency Contact Phone Number

Child Information

Child’s Full Name

Age

Medical Information

Allergies

Medical Conditions / Special Needs

Does your child require medication while on-site?

Yes

No

If yes, please explain:

Bathroom & Diaper Information

My child is:

Fully potty trained

Needs occasional assistance

In diapers/pull-ups

Diapering Instructions (if applicable)

Feeding / Snack Information

Snack Permission

My child may have snacks provided by me

Food Restrictions / Dietary Concerns

Comfort & Behavior Information

Should staff know to help your child feel comfortable?

Authorized Pick-Up Persons

Individuals authorized to pick up my child:

Parent Acknowledgements

Please check each item: *

I understand that I must remain onsite while my child is in Child Watch.

I understand that Child Watch staff are not authorized to administer medication unless otherwise approved.

I confirm my child is free from fever, vomiting, diarrhea, or contagious illness within the last 24 hours.

I understand Somnium Fitness reserves the right to contact me for behavioral, medical, or safety concerns.

I understand Child Watch is a supervised play area and not individualized childcare.

I have reviewed and agree to the Somnium Fitness Child Watch Policies.

Liability Waiver & Consent

I, the undersigned parent/legal guardian, understand that participation in the Somnium Fitness Child Watch Program involves inherent risks associated with physical activity environments and interaction with other children. I voluntarily allow my child to participate and release Somnium Fitness, its owners, employees, and contractors from liability except in cases of gross negligence or willful misconduct.

In the event of an emergency, I authorize Somnium Fitness staff to seek emergency medical care if I cannot be immediately reached.

Parent / Guardian Signature

Clear

Somnium Fitness Child Watch Intake Form and Waiver