Bikram Yoga Portsmouth Childcare Waiver of Liability Child's Name: In diapers? Birth date: Permission to use bathroom alone? Special Notes: Allergies: Child's Name: In diapers? Birth date: Permission to use bathroom alone? Special Notes: Allergies: Child's Name: In diapers? Birth date: Permission to use bathroom alone? Special Notes: Allergies: Parent/Guardian Name: Address: Phone: Driver's License #: State:  Alternate Phone: Emergency Contact: Phone: Relation to Child: I, ________________________, understand that by signing this waiver I release and hold harmless Bikram Yoga Portsmouth, C+P Gallagher's Properties and any of its employees, trustees, childcare providers and agents from any liability as a result of personal injury or property damage occuring while the above child/children is/are in their care at Bikram Yoga Portsmouth. I understand that childcare services are provided only while I am present in the building and taking class. I understand that childcare service and costs are separate from my membership at Bikram Yoga Portsmouth and payable in cash or check only to the childcare provider.   I understand that if my child should become unconsolable during the class session, I am responsible to leave class and attend my child.  I have read and understand the Bikram Yoga Portsmouth Childcare Policy. Signature of Parent or Guardian Date