Emmaus United Church of Christ Nursery Registration
For children under age 3.
Child's Full Name *
Your answer
Nickname
Your answer
Age
Your answer
Birthday *
MM
/
DD
/
YYYY
Parent / Guardian Name(s)
Your answer
Address
Your answer
Phone Number(s) *
Your answer
Parent Email Address(s) *
Your answer
Baptized?
If Baptized, date of Baptism
Your answer
List any allergies (food, medicine, and environment) that the child may have:
Your answer
List any special needs or instructions:
Your answer
Photo / Video Release
Signature *
By entering your initials in the below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
Your answer
Submit
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