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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