Memorial Community Development Corporation
Childcare Ministry Registration Form
645 Canal St: Evansville, IN, 47713: Telephone: 812-423-7166
Program (Check All that apply):
FIRST SHIFT
WEEKEND
FIT-CAMP
Student Name:
First Name
Last Name
D.O.B:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age:
Race:
Sex (M or F):
Mother/Guardian:
First Name
Last Name
Home Phone:
Format: (000) 000-0000.
Email:
example@example.com
Address (if different from child):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer:
Work Ph:
Format: (000) 000-0000.
Cell:
Format: (000) 000-0000.
Annual Income:
Number in Household:
Father/Guardian:
First Name
Last Name
Home Phone:
Format: (000) 000-0000.
Address (if different from child):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer:
Work Ph:
Format: (000) 000-0000.
Cell:
Format: (000) 000-0000.
Annual Income:
Number in Household:
With Whom Does Student Live:
By signing and dating below, I certify that all information is correct.
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sowing seeds of obedience, respect, faith, and love.
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Medical Information:
Physicians Name:
Telephone:
Format: (000) 000-0000.
List Medications or Allergies below (Put N/A if not applicable):
Rows
Medications
Allergies
1
**What is your Hospital Preference:
Please explain any physical or mental conditions staff should be aware of:
Pick-up Authorization:
The following people are
authorized
to pick my child up from the Childcare program and can be contacted in case of an emergency.
1) Name:
Phone:
Format: (000) 000-0000.
Relationship to Student:
2)Name:
Phone:
Format: (000) 000-0000.
Relationship to Student:
3) Name:
Phone:
Format: (000) 000-0000.
Relationship to Student:
4) Name:
Phone:
Format: (000) 000-0000.
Relationship to Student:
5) Name:
Phone:
Format: (000) 000-0000.
Relationship to Student:
The following people are
NOT
authorized to pick my child up from the Childcare program.
1) Name:
Phone:
Format: (000) 000-0000.
Sowing seeds of obedience, respect, faith, and love.
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Next
Relationship to Student:
Name
First Name
Last Name
Phone:
First Name
Last Name
Relationship to Student:
Name:
First Name
Last Name
Phone:
First Name
Last Name
Relationship to Student:
EMERGENCY MEDICAL AUTHORIZATION
It is by my signature that in case of an emergency that my child will be given emergency medical care. I
understand that I will be contacted immediately or as soon as possible should I be away from the phone numbers
written within this application.
Parent/Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please answer the following questions:
1. Approximately what hours do you need childcare?
Rows
Monday
Tuesday
Wednesday
Thursday
Friday
1
2. Has your child attended a childcare program before? If so, when and where?
Yes
No
If so, when and where?
3. What would you like for your child to learn while attending the program?
4. Does your child attend Church or Sunday School regularly?
Yes
No
If so, where?
5. What are your expectations for Memorial Childcare Ministry?
6. Are you interested in participating in parent workshops and family activities?
Yes
No
Undecided
Sowing seeds of obedience, respect, faith, and love.
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