Church Nursery Registration Form
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Parent/Guardian
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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.
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.
In Case of Emergency
Please note the names of two people who only may pick up your child from the nursery.
First Trustee Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Second Trustee Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Signature
Signature Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: