Neelsville Nursery Registration
Please complete this form for anyone using nursery services at Neelsville Church
Child's First Name
Your answer
Child's Last Name
Your answer
Birth date
please include day, month, & year
MM
/
DD
/
YYYY
Please list allergies medical concerns or write "none."
Your answer
May your child receive goldfish crackers as a snack? If not, please provide a snack that is peanut free.
Parent/Guardian 1 Name (First and Last)
Your answer
Cell Number
Your answer
Can receive texts?
E-mail
Your answer
Parent/Guardian Name 2 (First and Last)
Your answer
Cell Number
Your answer
Can Receive Texts?
E-mail
Your answer
Address
Your answer
Please list names of all adults authorized to pick up your child.
Your answer
Home Phone Number
Your answer
Please list a name and number for someone else to be contacted in case of emergency when the parents cannot be reached.
Your answer
Does Neelsville Church have your permission to use photographs and/or videos of your child on social media, brochures, website, and other promotional uses?
A parent or guardian must remain on the church grounds while children are in class. If you do not have a cell phone that can be reached, please take a pager. Also please do not bring a child to the nursery who has been sick within 24 hours either with symptoms of illness or a fever of 100 degrees or higher. I also agree to hold Neelsville Church harmless for any injury that occurs on Neelsville Church property.
Please write your first and last name and write the date as your signature that all of this information is true
Your answer
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