Connect Moms group childcare registration form

Connect Mom's Group Registration Form

Your Name

Phone

Emergency Contact Name

Emergency Contact Phone

Will you be using our childcare program?

YesNo

If yes, please fill down below to register your child/children

1st Child's Name

Child's Age

Does your child have any allergies or dietary restrictions?

YesNo

If yes, please explain

Is your child potty trained?

YesNo

*Please note that our childcare volunteers will not be changing any diapers or taking your children to go to the toilet. We ask our volunteers to bring our children to us if/when it is time for them to go the bathroom

Is there anything else we should know about caring for your child?

2nd Child's Name

Child's Age

Does your child have any allergies or dietary restrictions?

YesNo

If yes, please explain

Is your child potty trained?

YesNo

Is there anything else we should know about caring for your child?

3rd Child's Name

Child's Age

Does your child have any allergies or dietary restrictions?

YesNo

If yes, please explain

Is your child potty trained?

YesNo

Is there anything else we should know about caring for your child?

4th Child's Name

Child's Age

Does your child have any allergies or dietary restrictions?

YesNo

If yes, please explain

Is your child potty trained?

YesNo

Is there anything else we should know about caring for your child?

5th Child's Name

Child's Age

Does your child have any allergies or dietary restrictions?

YesNo

If yes, please explain

Is your child potty trained?

YesNo

Is there anything else we should know about caring for your child?