Nursery Registration Form

Nursery Registration Form
Thank you for registering your child for the nursery. Our priority is to serve each child by making the nursery a place where they will feel safe, loved, and content.
Child's Name: *

First Name Last Name
Nickname:
Age: *
Date of Birth: *

Month Day Year
Date
All families using nursery services must be registered parishioners. Are you registered parishioners of St. Patrick Church of Merna? *

Yes No
Mass Preference: *

Sunday 9:00am Sunday 11:00am
Mother's Name: *

First Name Last Name
Father's Name: *

First Name Last Name
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mother's Cell Phone: *
Please enter a valid phone number.
Father's Cell Phone: *
Please enter a valid phone number.
Mother's Email: *
example@example.com
Father's Email: *
example@example.com
Person to Notify in Case of an Emergency: *

First Name Last Name
Emergency Contact's Phone Number: *
Please enter a valid phone number.
Allergies or Medical Concerns? (If none, please type "none".) *
Child is comforted by:

Blanket Pacifier Music Stuffed Animal Other
Release

In consideration for allowing my child(ren) participate in the nursery, I hereby release and agree to indemnify and hold harmless St. Patrick Church of Merna, the parish's employees and agents, and the volunteers assisting the parish, from any and all liabiliy for injuries, medical expenses, or any other loss suffered to my child(ren), our family, or me due to my child's participation in this nursery.
Mother's Signature *

Clear
Father's Signature *

Clear
Should be Empty: