Office Use Only
Payment:
Parent/child Relation:
CHILD CARE & YOGA WAIVER OF LIABILITY
____________________________________
Child’s Last Name, First Name
__________________
Child’s Date of Birth
________________________________________
Parent/Legal Guardian Last Name, First Name
_______________
Today’s Date
Paid for by:
Entered By:
________________________________________
Parent email (for lost and found, etc.)
_____________________________________________________________________________________
Address
City
State
Zip
_______________________________
Phone
_______________________________________________
Driver’s License Number & State
_____________________________________________________________________________________
Emergency Contact Name & Phone
In Diapers?
Yes
No
Would you like child care attendee to change diaper if needed?
Yes
No
Allergies: _________________________________________________________________________________
Special Instructions: _________________________________________________________________________
Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement
Notice: This is a legally binding agreement.
I understand that by signing this Child Care & Yoga Waiver of Liability, I release and hold harmless Hapa Yoga LLC, and its owners,
directors, officers, advisors, employees, agents, instructors, volunteers, childcare workers, and all other persons or entities acting for
them from any and all claims, demands, suits, cost and charges, in connection with or arising out of Hapa Yoga services provided to
my child including but not limited to, personal injury, bodily harm, injury, or property damage occurring while the above child is
receiving services at Hapa Yoga. I understand that child care services are provided on an unlimited basis to those who have
purchased unlimited child care packages only, and that all child care sessions have a 90-minute time limit before incurring
additional fees, including unlimited child care memberships. All sessions that are not part of unlimited childcare memberships must
pay the set child care fee. I understand that if my child should become inconsolable during the class session, I am responsible to
leave class and attend to my child. I will be responsible to feed my child and have my child use the restroom prior to start of class
time. I understand I must remain in the Hapa Yoga Studio at all times.
I have read, reviewed and understand the Hapa Yoga Childcare and Child Yoga Policies and Rules:
_________________________________
Signature of Parent / Legal Guardian
______________________________________
Printed Name of Parent/Legal Guardian
Copyright © 2012 Hapa Yoga LLC/Hapa Yoga South Corp. All rights reserved.
____________
Date
HAPA YOGA CHILDCARE/CHILDREN’S YOGA RULES & REGULATIONS
Hapa Yoga’s child care room is an unlicensed child care providing a bright, clean, and safe environment for your child while
you use our fitness facility. Our staff is carefully interviewed and hired so that your kids are supervised by an AED/CPR
certified loving, attentive and responsible person at all times. We invite you get to know our child care staff and provide
feedback or questions at any time.
PLEASE INITIAL NEXT TO EACH NUMBERED ITEM INDICATING IT HAS BEEN READ AND IS UNDERSTOOD:
GENERAL
1. ____ The Childcare room is provided as a convenience, but is not considered as part of a member’s agreement privileges. Said
service may be provided or discontinued at the option of Hapa Yoga.
2. ____ A Childcare Release Form must be signed prior to first visit and every year after. An acknowledgement of having read and
received the latest version of the Rules and Regulations must also be signed upon your first visit.
3. ____ Child(ren) must be at least 6 weeks of age to be admitted. Infants who cannot sit without assistance should arrive in their
carrier. Please notify us 24 hours in advance if you will be bringing in an infant under 6 months of age.
4. ____ A maximum of ten children will be allowed in the child care room due to space limitations. Children will be admitted
on a first-come first-serve basis. Hapa Yoga will do our best to keep a ratio of six children per attendee, but this is not
guaranteed.
5. ____ Parents are required to sign their child(ren) in and out at each visit.
6. ____ Childcare is limited to a 90 Minute Maximum per child care session. A $5 fee will be charged for every 30 minutes over
the 90 minute period, per child. If you plan to attend more than one class per day, there must be one hour of time in
between where the child is removed from the premises to attend to child’s needs.
7. ____ Children with any visible signs of sickness will not be permitted. These symptoms include but are not limited to: runny
nose with yellow or green mucus, fever, wet cough, pink eye, rashes, etc. Childcare staff will NOT administer any type of
medication.
8. ____ If any child is inconsolable for over 10 minutes, parents will be pulled out of class to console your child or may be
asked to leave with refund. This is to ensure an enjoyable experience for other children, staff, and members in class.
9. ____ Parents must remain in the Hapa Yoga facility while children are in the childcare room or kids yoga. No exceptions.
10. ____ Children are NOT allowed unsupervised in the lobby, hallway or restrooms.
11. ____ Only children of Hapa Yoga members, parents, and Hapa Yoga staff are permitted in the childcare room. If your child is
accompanied by a non-member’s child, a written consent form from the visiting child’s parent is required. Visiting child must be
accompanied by a family member or paid child care provider.
PERSONAL ITEMS
12. ____ Food is NOT permitted in the childcare room, no exceptions. Please refrain from bringing food in backpacks or diaper
bags. Please feed your children outside of Hapa Yoga premises.
13. ____ Spill proof cups containing water are permitted for toddlers and prepared baby bottles are acceptable for infants. Items must
be labeled with the child’s name.
14. ____ Toys from home are permitted at the staff’s discretion. Staff is not responsible for lost, stolen or left behind items. We
recommend bringing activities or toys from home for children over the age of 8 as long as they are not a choking hazard.
POTTY TRAINING & DIAPERING
15. ____ If diapering is permitted, parents must provide diapers and wipes for their child, along with a change of clothes. Diaper bags
must also be labeled with child’s name. We will do our best to change diapers but it is not a guaranteed service, due to
time limitations or safety of other children being left unattended.
16. ____ Hapa Yoga sells diapers for $2.00. If diapers are not brought in and our supply is used, we will automatically charge the credit
card on file for use. We cannot guarantee that we will have correct size in-stock.
17. ____ If a child has a dirty diaper at the time of entering the childcare room, it is the responsibility of the parent to change the
diaper before he /she leaves to work out. Only diapers that become wet or soiled while the child is in the care of the staff
will be changed.
18. ____ Staff does not change diapers of children ages 3 years and older.
19. ____ If your child is potty training please notify the staff during sign in and bring a change of clothes in case of accident.
DISCIPLINE
20. ____ Childcare staff will use only verbal reprimand for inappropriate behavior or language. Several warnings may result in the
parent being called in. If child is unable to regain proper behavior, the child and parent will need to leave for remainder
of the day without refund. This is to ensure the safety and environment for the other children, members and staff. Examples
of inappropriate behavior include but are not limited to: hanging from, climbing on, or jumping off furniture; banging on walls or
glass; hitting or biting other children or staff; coloring on walls, furniture, or carpet, bullying, talking about inappropriate things
such as violence or name calling.
I have read and understand the Hapa Yoga Childcare/Children’s Yoga Rules and Regulations:
___________________________________________________________ __________________
(signature of parent/guardian
(today’s date)
Copyright © 2012 Hapa Yoga LLC/Hapa Yoga South Corp. All rights reserved.