Mentor United Methodist Church Children & Family Ministries
Registration for ALL Programs 2017-2018
Child’s Full Name
Your answer
Date of Birth
MM
/
DD
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YYYY
Gender
Home Phone Number
Your answer
Current Grade in School
Parent 1 Name
Your answer
Parent 1 Email Address
Your answer
Home Address
Your answer
Parent 1 Cell Phone Number
Your answer
Parent 2 Name
Your answer
Parent 2 Email Address
Your answer
Parent 2 Cell Phone Number
Your answer
Your answer
Any allergies, dietary restrictions, or other concerns you would like to share
Please share ANY concerns regarding allergies, dietary restrictions, etc.
Your answer
My child has permission to have nut-free snacks
On Sunday mornings children in the Early Childhood Area will be released through the check out system. Children in Grades K-6 need to be picked up by a parent or other adult. Please list individuals who have permission to retrieve your child:
Your answer
Additional information to share
Your answer
Emergency Contact 1 Name
Your answer
Emergency Contact 1 Phone Number
Your answer
Emergency Contact 1 Relationship to Child
Your answer
Emergency Contact 2 Name
Your answer
Emergency Contact 2 Phone Number
Your answer
Emergency Contact 2 Relationship to Child
Your answer
List things your child enjoys
Your answer
List things that calm or comfort your child
Your answer
Child’s Doctor & Phone Number
Your answer
Child’s Dentist & Phone Number
Your answer
Preferred Hospital
Your answer
Emergency Waiver~ In the event that reasonable efforts to contact me have been unsuccessful, I hereby give my consent for emergency medical treatment by a certified first aid giver. In the event that additional treatment is needed, the staff of the Emergency Department of the hospital listed above or the closest one to the event location, has my permission to treat my child.
Hospitalization Plan and Group #
Your answer
Please check the areas in which you’d be able to assist in our Children’s Ministry
Required
Typing your name here constitutes an electronic signature.
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