Nursery Registration

* Indicates a REQUIRED field.

Child Information
How Many Children Are You Registering?
Child 1 Name
First Last
Current Age
Date of Birth
MM slash DD slash YYYY
Allergy or Medical Conditions?
Child 2 Name
First Last
Child 2 Name
First Last
Child 2 Name
First Last
Current Age
Date of Birth
MM slash DD slash YYYY
Allergy or Medical Conditions?
Child 3 Name
First Last
Child 3 Name
First Last
Current Age
Date of Birth
MM slash DD slash YYYY
Allergy or Medical Conditions?
Child 4 Name
First Last
Current Age
Date of Birth
MM slash DD slash YYYY
Allergy or Medical Conditions?
Parent Information
Parent/Guardian Name*
First Last
Address*
Street Address City State ZIP Code
Parent/Guardian Email Address*
Parent/Guardian Primary Phone Number*
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
Anything Else We Need To Know?
Additional Person Authorized to Pick Up/Check Out Child
First Last
Contact Number for Authorized Person
Alternate pick-up person may be required to provide photo ID if requested.
Permission To Use Photos*
Please indicate your permission for your family members' image to be used as described below by completing this section: In order to protect our children and youth, we use photos and video taped images without names in our print, broadcast, and digital publicity - for example, in the Focus newsletter, on our website, on bulletin boards within the Church building, and in other communications media.
- I give permission for my child(ren)'s image to be used without names as described above
- I do NOT give permission
Phone
This field is for validation purposes and should be left unchanged.

Nursery Registration

Child Information

Parent Information