Resurrected Baptist Church Nursery Registration Form
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Any Allergies or Medical Conditions?
Yes
No
Please give details
Do you want to add something about your child?
Date
-
Month
-
Day
Year
Date
By checking this box, I agree that I am the legal guardian of the child/children on the form.
By checking this box, I agree to the Policies and Procedures written in the Resurrected Baptist Church Nursery Manual.
Signature
Submit
Submit
Should be Empty: