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Nursery Registration
815
2021-05-17T22:20:13-05:00
Nursery Registration
* Indicates a REQUIRED field.
Child Information
How Many Children Are You Registering?
1
2
3
4
Child 1 Name
First
Last
Current Age
Under 1 year old
1 year old
2 years old
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
Under 1 year
1 year old
2 years old
Date of Birth
MM slash DD slash YYYY
Allergy or Medical Conditions?
Child 3 Name
First
Last
Child 3 Name
First
Last
Current Age
Under 1 year
1 year old
2 years old
Date of Birth
MM slash DD slash YYYY
Allergy or Medical Conditions?
Child 4 Name
First
Last
Current Age
Under 1 year
1 year old
2 years old
Date of Birth
MM slash DD slash YYYY
Allergy or Medical Conditions?
Parent Information
Parent/Guardian Name
*
First
Last
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Name
This field is for validation purposes and should be left unchanged.
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