Church Nursery Registration Form
Child's Legal Name
First Name
Last Name
Name child likes to be called
Date of Birth
-
Month
-
Day
Year
Date
Age
Parent/Guardian
Name
First Name
Last Name
Phone Number during worship
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Getting Familiar With Your Child
1. Please select the preferred bottle option if age appropriate.
When fed
Pre-Prepared
Warmed
Cold
2. Is your child allowed to have snacks?
Yes
No
3. What are the favorite activities of your child?
4. What annoys your child at most?
5. Is your child allergic to anything?
Yes
No
Please specify what your child is allergic to.
Pick Up and In Case of Emergency
Please note the names of two people who only may pick up your child from the nursery.
First person allowed to pick up child
First Name
Last Name
Phone Number
Please enter a valid phone number.
Second person allowed to pick up child
First Name
Last Name
Phone Number
Please enter a valid phone number.
Parent/Guardian Signature
Signature Date
-
Month
-
Day
Year
Date
I, undersigned, agree with the following statements:
I am the parent/guardian of the child indicated above.
If emergency medical care is needed and I am unavailable, I authorize the supervising teacher to seek medical treatment for my child.
I am giving my permission to take my child's pictures for classroom projects and post them on the church website and other PUMC publications print or online. Your child's identity will never be shared in any way.
Submit
Submit
Should be Empty: