Family Agreement Form

Complete this form to acknowledge the Kellie's Table Family Agreement.

Parent / Guardian

Parent / Guardian Name *

Parent Email *

Parent Phone *

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Services Select all that apply.

Reading Kitchen Art KeepsakePhoto Books

Children

Child 1

Child's Name *

Child's Age

Allergies / Restrictions / Medical Notes

Photo Permission * Yes, I give permission for this child to appear in photos used by Kellie’s Table. No, I do not give permission for this child to appear in photos used by Kellie’s Table.

Your child’s name or any other personal information will not be shared.

Authorized Pickup Persons

List anyone besides the parent/guardian who is allowed to pick up your child.

Name

Relationship

Phone

Final Confirmation I confirm that I am the parent/legal guardian of the child or children listed above and agree to the Kellie’s Table Family Agreement, including any service-specific policies that apply.