Family Agreement Form

Complete the information below to acknowledge the Kellie's Table Family Agreement.

Need to review the policies first?
Read the Family Agreement.

Family Agreement & Policies

This form records your acknowledgement of the Kellie's Table Family Agreement and any applicable service-specific policies.

Parent / Guardian Name *

Parent Email *

Parent Phone *

Child's Name *

Child's Age

Emergency Contact Name *

Emergency Contact Phone *

Allergies / Restrictions / Medical Notes

Service Requested Select all that apply

Kitchen Table

Reading Table

Art Table

Keepsake Photo Books

Authorized Pickup Persons

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

Photo Permission

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

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

Parent / Guardian Signature

Electronic Signature *

Signature Date *

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