North Raleigh Community Church
Child Registration and Emergency Information
Personal Information
Please select which class your child participates in at church. *
Child's Last Name *
Your answer
Child's First Name *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's School (if applicable)
Example: Daycare/Preschool, Elementary School, etc.
Your answer
Child's Grade Level (if applicable)
Example: two year old class, 9th grade, etc
Your answer
Parent's Name *
(First and Last)
Your answer
Parent's Phone Number *
Your answer
Parent's Email *
Your answer
Additional Parent Name
(First and Last)
Your answer
Additional Parent Phone Number
Your answer
Additional Parent Email
Your answer
What should we know to care for your child well?
Your answer
Does your child have any special concerns? If so, please describe. *
(Allergies, Medications, Medical Conditions, etc.)
Your answer
Is your child allowed to have food and drink provided by NRCC teachers? *
Items might include snack crackers, juice boxes, goods baked by teachers, etc.
Medical Release Waiver
*
Required
What is your Emergency Room Preference?
Your answer
*
Required
I understand that providing my first and last name in the box below constitutes a signature confirming that I acknowledge and agree to the above information and statements. *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms