2025 Influence Conference Child Care Registration
This form is available until November 20th, 2025
Information of Child/Children
Child One
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Age
*
Child Two
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Age
Child Three
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Age
Child Four
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Age
Child Five
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Age
Hours of child care: Drop off Saturday morning beginning at 9:00 a.m. and pick up after service concludes. If pickup during lunch, please pick up by 12:30 p.m and drop off after lunch at 2:00 p.m. If leaving your child during lunch, pizza will be provided at no cost.
Please note that Infant and Toddler Nursery Have Limited Space.
I will need to reserve space in the:
*
Infant/Toddler Nursery: Ages 0-2 years old
Preschool Room: Ages 3 - 5 years old
Kids Service: Kindergarten - 5th Grade
I am leaving my kids in child care during Lunch/Midday Bash
*
Yes (pizza is provided at no cost)
No, I will pick up my child and provide their lunch.
Information of Parent
Parent/Guardian One
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Parent/Guardian Two
First Name
Last Name
Phone Number
Please enter a valid phone number.
Special Information
Infants Only: Feeding Instructions? Diaper Instructions?
Toddler Only: Potty Trained? If no, any diaper or potty instructions?
For each child, please list any food allergies:
I acknowledge that whoever picks up my child/children from child care will need the pick up tag that I will receive when I drop them off.
*
Yes
No
I acknowledge that I give my permission for my child/children to attend this event.
*
Submit
Should be Empty: