Nursery Registration Form

Date__________

PLEASE COMPLETE ONE FORM PER CHILD.

Child's Name

Child's Nickname

Date of Birth

Gender

Male Female Non-binary

Family Connections

Full Name of Parent/Guardian #1

Phone of Parent/Guardian #1

Full Name of Parent/Guardian #2

Phone of Parent/Guardian #2

Allergies

Food

Medicine

Other

Important Information

Who do we contact in case of an emergency?

Is there anything you'd like for us to know about your child (potty training, ways to comfort...)

Authorization and Consent of Parent(s) or Legal Guardian for Medical Treatment

I grant my authorization and consent for St James’ Episcopal Church staff to administer general first aid treatment of any minor injuries or illnesses experienced by the Minor. I understand in an emergency situation, emergency services will be contacted.

Do we have permission to administer general first aid treatment of any minor injuries or illnesses experienced by your child?

Yes No

Media Release

I understand that photos or videos or audio of my child may be taken during family ministries activities and/or other church events. I consent to the use of my child's photo, voice, or likeness in promotional materials such as the church website, newsletter, brochures, bulletin, and social media outlets. I understand that my child's identifying information will not be provided unless I give permission at a later time.

Do we have permission to photograph and record your child?

Yes No

Parent/Guardian signature

Signature

Today's Date

Description

Please fill out this form and click submit.

Nursery Registration Form

Description

Please Fix the Following