Shelter From the Storm Gala Childcare
February 10th from 4:00-7:00 pm - Childcare will take place at Sun Prairie United Methodist Church
Child's Name (1) *
Your answer
Birth Date *
Your answer
Grade *
Your answer
Allergies and/or Health/Ed Concerns *
Your answer
Child's Name (2)
Your answer
Birth Date
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Grade
Your answer
Allergies and/or Health/Ed Concerns
Your answer
Child's Name (3)
Your answer
Birth Date
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DD
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YYYY
Grade
Your answer
Allergies and/or Health/Ed Concerns
Your answer
Parent/Guardian Name *
Your answer
Phone Number that you can be reached at during the event. *
Your answer
Email Address *
Your answer
Address *
Your answer
Emergency Contact person during the event. Name and Phone number *
Your answer
In an event of illness or accident, and if the parent/guardian can not be reached, I authorize Sun Prairie United Methodist Church or its agent to transfer my child to the hospital. My electronic notation on this form authorizes church leaders to consent to any emergency diagnosis, examination, treatment, or hospital care for my child who is deemed advisable by and is of an accident or illness in connection with any authorized church activities. I will assume responsibility for all medical expenses incurred on behalf of my child.
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Hospital *
Your answer
Physician *
Your answer
Physician Phone Number *
Your answer
Please list any other information below that you feel event organizers need to know about caring for your child.
Your answer
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