Nursery Registration (0-4 years)

Child's Full Name *

Child's Birthdate *

Child's Gender

gender.male

gender.female

Child's Photo

Home Address

manageMemberFields.fields.AddressLine

common.city

common.area

manageMemberFields.fields.ZipCode

manageMemberFields.fields.Flat

Parent/Guardian Full Name *

Parent/Guardian Mobile Phone *

Parent/Guardian Email

Relationship to Child

Emergency Contact Name

Emergency Contact Phone

Allergies, medical conditions, medications (please list)

Names & phone numbers of other authorized pickup persons

Permissions and consents (select all that apply)

Diapering and routine care (diaper changes)

Application of diaper cream (if provided)

Feeding (bottles/solids provided by parent)

Administer basic first aid (non-prescription)

Photographs for church use (announcements, bulletin boards)

Signature

Full Name *

Parent/Guardian Signature *common.clear