Child Registration Form
A nonrefundable registration fee will be processed prior to or upon completion of this form to be considered for services with Natasha’s Nurturing Nest, LLC. A new registration fee is applied when contracts end and services are not continued. Families must sign a Service Contract Agreement before care is rendered.
Care Schedule
families must remain under similar schedules aside from school transportation/extracurricular activities.
My child (ren) will receive childcare and adhere to the following schedule:
*
5 days
4 days
3 days
2 days
1 day
Swim lessons
Afterschool care only
Prolonged care (overnight/weekends)
Convenience care
Back
Next
Child(ren) Background
Number of Children
*
Please Select
One (1)
Two (2)
Three (3)
Four (4)
Child 1: Name
*
First Name
Last Name
Child 1: Date Of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Child 1: Gender
*
Please Select
Female
Male
Not Listed/Prefer Not to Say
Child 1: Age
*
Child 1: School
*
Child 1: Grade
*
Child 1: Time
*
Hour Minutes
AM
PM
AM/PM Option
Child 1: Activities & Homework Requests
Child 1: Interest & Hobbies
Child 2: Name
First Name
Last Name
Child 2: Date Of Birth
-
Month
-
Day
Year
Date Picker Icon
Child 2: Gender
Please Select
Female
Male
Not Listed/Prefer Not to Say
Child 2: Age
Child 2: School
Child 2: Grade
Child 2: Time
Hour Minutes
AM
PM
AM/PM Option
Child 2: Activities & Homework Requests
Child 2: Interest & Hobbies
Child 3: Name
First Name
Last Name
Child 3: Date Of Birth
-
Month
-
Day
Year
Date Picker Icon
Child 3: Gender
Please Select
Female
Male
Not Listed/Prefer Not to Say
Child 3: Age
Child 3: School
Child 3: Grade
Child 3: Time
Hour Minutes
AM
PM
AM/PM Option
Child 3: Activities & Homework Requests
Child 3: Interest & Hobbies
Child 4: Name
First Name
Last Name
Child 4: Date Of Birth
-
Month
-
Day
Year
Date Picker Icon
Child 4: Gender
Please Select
Female
Male
Not Listed/Prefer Not to Say
Child 4: Age
Child 4: School
Child 4: Grade
Child 4: Time
Hour Minutes
AM
PM
AM/PM Option
Child 4: Activities & Homework Requests
Child 4: Interest & Hobbies
Back
Next
Parent/Guardian Background
Parent/Guardian 1: Name
*
First Name
Last Name
Parent/Guardian 1: Email
*
example@example.com
Parent/Guardian 1: Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/Guardian 1: Employer
*
Parent/Guardian 1: Occupation
*
Parent/Guardian 1: Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1: Work
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian2: Name
*
First Name
Last Name
Parent/Guardian 2: Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/Guardian 2: Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2: Email
example@example.com
Demographics
This information will remain confidential and is only used for data collection and reports.
Ethnicity (check all that apply)
*
Asian American/Pacific Islander
Black/African American
Latin/Hispanic/Latin American
Middle Eastern/North African
Multi-racial/More than one race
Native American/Alaska Native/Ingenious
White/Caucasian
Do not want to disclose
Other/Not listed
Primary Home Language Spoken: (check one)
*
English
French
Italian
Spanish
Mandarin
Other/Not listed
Back
Next
Emergency Contact
I authorize the nanny to release my child (ren) to the following people below with presentation of a valid state issued identification card.
Emergency Contact 1: Name
*
First Name
Last Name
Contact 1: Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact 1: Relationship to Child(ren)
*
Contact 1: Release day & times
*
Emergency Contact 2: Name
*
First Name
Last Name
Contact 2: Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact 2: Relationship to Child(ren)
*
Contact 2: Release day & times
*
Back
Next
Parent/Guardian Consent
Please put your initials by each statement you agree to adhere to during the life of your contract with Natasha’s Nurturing Nest, LLC.
I give my child (ren) permission to be photographed, filmed or recorded solely for the purpose of marketing, advertising and branding. No compensation will be provided for the use of photograph.
*
Yes
No
I give my child (ren) permission to be photographed, filmed or recorded solely for the purpose of marketing, advertising and branding. No compensation will be provided for the use of photograph.
*
Yes
No
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Signature Here
*
Your signature acknowledges you have read, understand and agree to the above information.
Date
*
-
Month
-
Day
Year
Date Picker Icon
Print
SUBMIT
Should be Empty: