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Family and Household Client Intake Form

Welcome! Please complete this one-time form to help Chronically Kind provide you safe, personalized childcare.

We ask you update this important form any time you have life changes such as a new child, address change, new medical condition, etc.

Primary Contact and Family Info

Residential Address

Guardian 1 - Primary

Guardian 1 First Name (Legal)

Guardian 1 Last Name (Legal)

Nickname or Preferred Name

Relationship to Child(ren)

Email Address

Phone

Guardian 2 - Optional

Guardian 2 First Name (Legal)

Guardian 2 Last Name (Legal)

Nickname or Preferred Name

Relationship to Child(ren)

Email Address

Phone

Children's Details

Full Legal Names of Children

Include preferred names if different than legal names.

Birthdays and Current Age

List any known allergies and if you have an Epi pen indicate the location of it

N/A if this doesn't apply

Are there special circumstances or medical conditions to be aware of?

N/A if this doesn't apply

Emergency Contacts

First and Last Name

Phone Number

Address

Relationship

Household Access and Logistics

Is there a gate access code?

Is there a specific entry method to be aware of? A certain key, code or access point?

Outline parking notes and instructions please.

House Rules and Routines

Describe bed and naptime routines and timing.

Detail any dietary restrictions or preferences.

Outline house rules around screen time.

Detail additional house rules, such as no shoes in the house, close the garage door, food can be shared or not, etc.

List rules and expectations around carers eating or not eating your pre-purchased food and drinks in the house.

Child Behaviour and Preferences

List likes and interests.

List, dislikes and known triggers.

Outline any behaviors of note (shyness, easily, frustrated, etc.)

Are there comfort strategies that work for these triggers?

Pets (if applicable)

What are the types and names of pets in the home?

N/A if not applicable

Are the pets and children comfortable around one another?

Final Notes

Use this space however you want. We are great listeners!

How did you find us?

Permissions and Authorizations

Do you permit photography and videography during care?

Allowed for marketing purposes

Allowed only to send parent/guardians updates

Allowed for personal sharing - (Not shared online/social media)

Not allowed

Any guidelines to share regarding videography and photography during care shifts?

Chronically Kind LLC will take reasonable steps to respond to medical emergencies involving your children, including calling emergency services if necessary.

You acknowledge by submitting this form that Chronically Kind LLC does not provide or coordinate medical care and is not responsible for emergency outcomes.

Are there additional notes on emergency procedures or transport if ever applicable?

I confirm that the information given is accurate, and I agree to present valid identification for verification at the request of the provider.

Physical ID required. Photos will not be stored by Chronically Kind LLC or it's independently contracted caregivers.)

Signature

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Thank you for taking the time to fill out this form it helps us to do our best to serve and care for your family!

Chronically Kind LLC

Carer Release of Liability and

Waiver of Claims

Effective Date: August 01, 2025 Applies to: All carers (parents/legal guardians) registering a child or dependent to receive care services through ChronicallyKind.com

1. Acknowledgment of Services

I, the undersigned, understand that ChronicallyKind.com is a platform that connects carers (parents/legal guardians) with independent care providers for childcare services provided in private homes and public settings.

Chronically Kind LLC does not directly employ these care providers and does not supervise, control, or assume responsibility for their actions, conduct, or qualifications.

2. Assumption of Risk

I acknowledge and voluntarily accept the inherent risks involved in leaving my child(ren) or dependent(s) in the care of an individual introduced through ChronicallyKind.com or ChronicallyKindLife.com.

I understand that childcare involves physical activity, emotional support, and social interaction, all of which carry the potential for injury, harm, illness, or loss. I acknowledge that these risks may arise from:

The nature of care activities
The behavior or actions of care providers or others present
Environmental factors at care locations (e.g., homes, parks, public venues)

I accept full responsibility for these risks and for determining the suitability of each care provider for my child or dependent.

3. Release and Waiver of Liability

In consideration of using ChronicallyKind.com and the associated care services, I agree to the following:

I release, waive, and discharge ChronicallyKind.com, its founders, directors, officers, employees, agents, volunteers, affiliates, and contractors ("Released Parties") from any and all claims, demands, actions, or causes of action arising out of or related to injury, damage, or loss sustained by my child(ren), my dependent(s), or myself as a result of receiving services through the platform.
This waiver includes, without limitation, claims arising from negligence (excluding gross negligence or willful misconduct), personal injury, emotional distress, or property damage.

4. Medical Emergencies

I authorize care providers engaged through Chronically Kind LLC to take reasonable steps to respond to medical emergencies involving my child, including calling emergency services if necessary.

I acknowledge that Chronically Kind LLC does not provide or coordinate medical care and is not responsible for emergency outcomes.

5. Indemnification

I agree to indemnify and hold harmless the Released Parties from any claims, costs, or damages (including legal fees) arising from:

My child’s or dependent’s use of care services
My violation of any applicable laws or regulations

Any breach of this waiver or related terms

6. Parental Authority

I affirm that I am the parent or legal guardian of the child(ren) or dependent(s) being registered for services. I have the legal right to enter into this agreement on their behalf.

7. Governing Law

This Release and Waiver shall be governed by and interpreted in accordance with the laws of the State of Florida, without regard to conflict of law principles.

8. Acknowledgment and Consent

By signing below, I acknowledge that I have read and understood this Release and Waiver of Liability, and that I voluntarily agree to its terms.

By selecting this checkbox and completing my digital signature, I acknowledge that I have read and agree to the Chronically Kind LLC Carer Release of Liability and Waiver of Claims

I confirm that the information given is accurate, and I agree to present valid identification for verification at the request of the provider. (Physical ID required. Photos will not be stored by Chronically Kind LLC or it's independently contracted caregivers.)

Signature

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First name (Legal)

Last name (Legal)

Date

Month

Day

Year

Child 1 Name

Child 2 Name

Child 3 Name

Child 4 Name

Terms and Conditions

Family and Household Client Intake Form

Primary Contact and Family Info

Children's Details

Emergency Contacts

Household Access and Logistics

House Rules and Routines

Child Behaviour and Preferences

Pets (if applicable)

Final Notes

Permissions and Authorizations

Chronically Kind LLC

Carer Release of Liability and

Waiver of Claims

1. Acknowledgment of Services

2. Assumption of Risk

3. Release and Waiver of Liability

4. Medical Emergencies

5. Indemnification

6. Parental Authority

7. Governing Law

8. Acknowledgment and Consent

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Sign-up Below!

CONTACT US

Family and Household Client Intake Form

Primary Contact and Family Info

Children's Details

Emergency Contacts

Household Access and Logistics

House Rules and Routines

Child Behaviour and Preferences

Pets (if applicable)

Final Notes

Permissions and Authorizations

Chronically Kind LLC

Carer Release of Liability and

Waiver of Claims

1. Acknowledgment of Services

2. Assumption of Risk

3. Release and Waiver of Liability

4. Medical Emergencies

5. Indemnification

6. Parental Authority

7. Governing Law

8. Acknowledgment and Consent

Stay in the know. Sign-up Below!

CONTACT US

Stay in the know.
Sign-up Below!