WeeCare Registration
A mother's day out program
Helmar Lutheran Church
Newark, Illinois
Email address *
Child's Name *
Your answer
Child's birthdate *
MM
/
DD
/
YYYY
Parents/Guardians Names *
Your answer
Address *
Your answer
Email *
Your answer
Primary Contact Phone with name *
Your answer
Secondary Contact Phone with name *
Your answer
Home church
Your answer
Allergies or medical concerns
Your answer
My child's photograph may be used for the purpose of publications and/or on the church's website as part of the children's ministry program at Helmar Lutheran Church. *
What are three of your child's favorite things to do?
Your answer
Anything else you would like us to know?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service