Mentor United Methodist Church Children & Family Ministries
Registration for ALL Programs 2018-2019 for kids birth through 6th grade.
Parent 1 Name *
Your answer
Parent 1 Primary Phone Number *
Your answer
Parent 1 Text on Primary Phone? *
Parent 1 Email Address *
Your answer
Parent 1 Home Address *
Your answer
Parent 2 Name
Your answer
Parent 2 Primary Phone Number
Your answer
Parent 2 Text on Primary Phone?
Parent 2 Email Address
Your answer
1st Child’s Last Name *
Your answer
1st Child’s First Name *
Your answer
1st Child's Date of Birth *
MM
/
DD
/
YYYY
1st Child's Gender *
1st Child's Current Grade in School *
1st Child's allergies, dietary restrictions, or other concerns you would like to share *
1st Child: Please share ANY concerns regarding allergies, dietary restrictions, etc.
Your answer
1st Child's has permission to have nut-free snacks *
1st Child: Do you agree to allow photos/videos of your child to be used in church presentation or church promotional materials? *
1st Child: Do you agree to allow photos/videos of your child to be used online? *
2nd Child’s Last Name (if different)
Your answer
2nd Child’s First Name
Your answer
2nd Child's Date of Birth
MM
/
DD
/
YYYY
2nd Child's Gender
2nd Child's Current Grade in School
2nd Child's allergies, dietary restrictions, or other concerns you would like to share
2nd Child: Please share ANY concerns regarding allergies, dietary restrictions, etc.
Your answer
2nd Child's has permission to have nut-free snacks
2nd Child: Do you agree to allow photos/videos of your child to be used in church presentation or church promotional materials?
2nd Child: Do you agree to allow photos/videos of your child to be used online?
3rd Child’s Last Name (if different)
Your answer
3rd Child’s First Name
Your answer
3rd Child's Date of Birth
MM
/
DD
/
YYYY
3rd Child's Gender
3rd Child's Current Grade in School
3rd Child's allergies, dietary restrictions, or other concerns you would like to share
3rd Child: Please share ANY concerns regarding allergies, dietary restrictions, etc.
Your answer
3rd Child's has permission to have nut-free snacks
3rd Child: Do you agree to allow photos/videos of your child to be used in church presentation or church promotional materials?
3rd Child: Do you agree to allow photos/videos of your child to be used online?
4th Child’s Last Name (if different)
Your answer
4th Child’s First Name
Your answer
4th Child's Date of Birth
MM
/
DD
/
YYYY
4th Child's Gender
4th Child's Current Grade in School
4th Child's allergies, dietary restrictions, or other concerns you would like to share
4th Child: Please share ANY concerns regarding allergies, dietary restrictions, etc.
Your answer
4th Child's has permission to have nut-free snacks
4th Child: Do you agree to allow photos/videos of your child to be used in church presentation or church promotional materials?
4th Child: Do you agree to allow photos/videos of your child to be used online?
5th Child’s Last Name (if different)
Your answer
5th Child’s First Name
Your answer
5th Child's Date of Birth
MM
/
DD
/
YYYY
5th Child's Gender
5th Child's Current Grade in School
5th Child's allergies, dietary restrictions, or other concerns you would like to share
5th Child: Please share ANY concerns regarding allergies, dietary restrictions, etc.
Your answer
5th Child's has permission to have nut-free snacks
5th Child: Do you agree to allow photos/videos of your child to be used in church presentation or church promotional materials?
5th Child: Do you agree to allow photos/videos of your child to be used online?
On Sunday mornings children in the Early Childhood Area will be released through the check out system. Children in Grades K-6 need to be picked up by a parent or other adult. Please list individuals who have permission to retrieve your child:
Your answer
Emergency Contact 1 Name *
Your answer
Emergency Contact 1 Phone Number *
Your answer
Emergency Contact 1 Relationship to Child *
Your answer
Emergency Contact 2 Name
Your answer
Emergency Contact 2 Phone Number
Your answer
Emergency Contact 2 Relationship to Child
Your answer
Pediatrician & Phone Number
Your answer
Dentist & Phone Number
Your answer
Preferred Hospital
Your answer
Emergency Waiver~ In the event that reasonable efforts to contact me have been unsuccessful, I hereby give my consent for emergency medical treatment by a certified first aid giver. In the event that additional treatment is needed, the staff of the Emergency Department of the hospital listed above or the closest one to the event location, has my permission to treat my child.
Hospitalization Plan and Group #
Your answer
Please check the areas in which you’d be able to assist in our Children’s Ministry *
Required
Typing your name here constitutes an electronic signature. *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Mentor United Methodist Church.