KidCity Registration Form
Hi there! We are so excited for you and your family to worship with us at Mosaic! You can pre-register your children by completing the questionnaire below. On Sunday morning, they will be in our check-in system and ready for worship! Thank you, and we look forward to meeting your family and worshipping with you!
Parent/Guardian Information
Name - Parent 1
*
First Name
Last Name
Name - Parent 2
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Best Contact Number - Parent 1
*
Please enter a valid phone number.
If you are not the parent of the child, what is your relationship to the child?
Your child(ren) may be photographed while participating in the activities of Mosaic Church. Do you give permission for photographs of your child(ren) to be used by Mosaic Church on its website, social media platforms, and other church materials?
*
Yes
No
Back
Next
Emergency Contacts
Name
*
First Name
Last Name
Best Contact Number
*
Please enter a valid phone number.
Relationship to Child/Family
*
Permission to pick-up child?
*
Yes
No
Name
First Name
Last Name
Best Contact Number
Please enter a valid phone number.
Relationship to Child/Family
Permission to pick-up child?
Yes
No
Back
Next
Child Information | Child 1
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Same address as parent/guardian?
*
Yes
No
Home Address (if different from parent/guardian)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name & Grade
*
So that we can best serve your child, please select all care needs that apply to your child.
*
Vision
Food Allergy
Diabetes
Communication (nonverbal, sign language, etc.)
Seizures
Fine Motor
Sensory Integration
Self Care Skills (using the bathroom, feeding, etc.)
Mobility
NONE
Other
Please list any additional information related to care needs selected above, as well as any other medical information we need to be aware of (i.e. Autism, ADHD). Please type N/A if there are none.
*
Does your child carry any medications, such as an epipen, inhaler, or insulin?
Back
Submit
Next
Child Information | Child 2
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Same address as parent/guardian?
Yes
No
Home Address (if different from parent/guardian)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name & Grade
So that we can best serve your child, please select all care needs that apply to your child?
Vision
Food Allergy
Diabetes
Communication (nonverbal, sign language, etc.)
Seizures
Fine Motor
Sensory Integration
Self Care Skills (using the bathroom, feeding, etc.)
Mobility
NONE
Other
Please list any additional information related to care needs selected above, as well as any other medical information we need to be aware of (i.e. Autism, ADHD). Please type N/A if there are none.
Does your child carry any medications, such as an epipen, inhaler, or insulin?
Back
Next
Child Information | Child 3
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Same address as parent/guardian?
Yes
No
Home Address (if different from parent/guardian)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name & Grade
So that we can best serve your child, please select all care needs that apply to your child?
Vision
Food Allergy
Diabetes
Communication (nonverbal, sign language, etc.)
Seizures
Fine Motor
Sensory Integration
Self Care Skills (using the bathroom, feeding, etc.)
Mobility
NONE
Other
Please list any additional information related to care needs selected above, as well as any other medical information we need to be aware of (i.e. Autism, ADHD). Please type N/A if there are none.
Does your child carry any medications, such as an epipen, inhaler, or insulin?
Back
Next
Child Information | Child 4
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Same address as parent/guardian?
Yes
No
Home Address (if different from parent/guardian)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name & Grade
So that we can best serve your child, please select all care needs that apply to your child?
Vision
Food Allergy
Diabetes
Communication (nonverbal, sign language, etc.)
Seizures
Fine Motor
Sensory Integration
Self Care Skills (using the bathroom, feeding, etc.)
Mobility
NONE
Other
Please list any additional information related to care needs selected above, as well as any other medical information we need to be aware of (i.e. Autism, ADHD). Please type N/A if there are none.
Does your child carry any medications, such as an epipen, inhaler, or insulin?
Submit
Should be Empty: