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REGISTRATION FORM

Child Information

Pets in Home?
Allergies?

Parent/Guardian Information

Emergency Contact

I, the above-named parent or guardian of the child or children listed above, am leaving my child or children with the Instant Care service from EBSquared Solutions and hereby release and waive against all claim of EBSquared Solutions, its agents, employees, volunteers, representatives, officers, directors, from injuries or damages arising from injuries relating to my child’s or children’s participation in the Instant Care service from EBSquared Solutions. I further agree to indemnify, save, and hold Indemnities harmless from any loss, liability, attorney fees, damage or cost that they (or any of them) may incur out of or related to the Instant Care services offered by EBSquared Solutions. In the case of a medical emergency or behavioral issue, I understand that the Instant Care service will act on my behalf if attempts to contact me have been unsuccessful.

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914-996-8551

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