Stay N Play Summer Registration

Emergency Contact Information
Please list three emergency contacts (other than parent/guardian) that we may contact in the event of an emergency. These people will also act as authorized adults to pick up you child.
Pickup Name 1

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Pickup Name 2

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Pickup Name 3

First NameLast Name
Phone Number

Area CodePhone Number
Relationship

Medical Information
Food Allergies*
Medical conditions that staff needs to be aware:*
Type 'None' if {childsName} has no medical conditions to report.
Family Doctor Name*
Family Doctor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Doctor Phone Number*

Area CodePhone Number
Upload Shot Records

Browse Files
You can use your smartphone to take a picture of your child's shot records and upload the picture(s). You can also opt to bring your child's shot records into the office. Cancelof
Upload Birth Certificate

Browse Files
You can use your smartphone to take a picture of your child's birth certificate and upload the picture. You can also opt to bring your child's birth certificate into the office. Cancelof

We would like to use pictures of your the KIDS@PUMC Preschool Programs student in brochures, on the church website, and Facebook page. We will not include students’ names or any other information.
Consent for use of picture(s)*

YesNo
Do you currently have a church home?

YesNo
I, {parentguardianName}, understand that I will be notified of {childsName}'s acceptance into the KIDS@PUMC Preschool Programs via email.

Upon {childsName}'s acceptance into the KIDS@PUMC Preschool Programs, I agree to pay a NON-REFUNDABLE registration fee in cash or check before 6:00 pm the next business day to hold my child's place.

I will also provide a completed emergency form/liability waiver and field trip permission slip no later than the first day of the program.

Please make checks payable to KIDS@PUMC Preschool Programs.
Signature*
Type Full Name
Date

MonthDayYear
Date
Should be Empty:

Parent/Guardian Information