Little Lights Nursery Registration Form
Child's Name:
First Name
Last Name
Nickname:
Parent or Guardian Information:
Parent 1 Name:
First Name
Last Name
Parent 1 Cell #:
Format: (000) 000-0000.
Parent 1 Email:
example@example.com
Parent 2 Name:
First Name
Last Name
Parent 2 Cell #:
Format: (000) 000-0000.
Parent 2 Email:
example@example.com
City/State/Zip:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Information About the Child:
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age of Child:
Diapering Instructions (select one option):
Diapering Instructions (select one option):
Volunteers may change
Parents only may change
Getting to Know Your Child:
Favorite activities:
Does not like:
Is allergic to:
Has your child ever been left in a child care nursery before?
Yes
No
Does your child have any special words for things that we should know? (Example: pacifier)
Yes
No
If yes, please give examples of special words.
Only these two additional people may pick up my child from the nursery:
1.
2.
Emergency Contact Information:
A parent/guardian is expected to be on church property when their child is being cared for in the church nursery so we can easily contact you if needed and a cell phone number should be provided above. You will be contacted via text message if your child needs your attention during worship.
Parent/Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: