Parent / Guardian Name *

First Name

Last Name

1st Child's Name *

First Name

Last Name

2nd Child's Name

First Name

Last Name

Date attending Church *

MM

DD

YYYY

Phone *

(###)

###

####

Please check all that apply about your child we need to be aware of *

Any Allergies

Medical Information

Special Concerns

None of the above

I understand I must provide diapers &/or prepared bottles if necessary *

Yes, I understand

Items not required for child(ren)

My child is toilet trained *

Yes

No

Parents, let's do our best to keep all of our kids and teachers healthy - If your child has had a fever in the past 48 hours, please keep them with you