Midsouth District Assembly Childcare Registration 2025
For ages 6 weeks to 5 years old.
Name of Child
*
First Name
Last Name
Age of Child
*
Name of Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Name of Additional Emergency Contact
First Name
Last Name
Phone Number of Additional Emergency Contact
Please enter a valid phone number.
Check dates/times that child will be in attendance
*
April 24th (Thursday Night)
April 25th (Friday Morning)
April 25th (Friday Afternoon)
April 25th (Friday Night)
Is your child potty trained?
*
Yes
No
Church Attended
*
Allergies, Medications, Other Medical Alerts or Concerns
*
Upon arrival there will be a sign in sheet to sign in your child for every service or drop off. Due to lack of cell service, we will be using popsicle sticks with numbers on them to alert you if we need you. Your Child's number will flash upon the screen in service in case you are needed. See you soon!
Submit
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