Mornings with Mommy Registration
Event date : April 9, 2021 at 10:00 am
Event Location: 6150 N. Lecanto Hwy Beverly Hills FL
Bugs and Spring time!
I agree to the following: I understand the following symptoms and affirm that I, as well as my household members, do not currently have, nor experienced these symptoms in the last 14 days: Fever/Chills, Fatigue, Dry cough/Sore throat, Difficulty breathing, Loss of smell or taste, Muscle aches. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. I affirm that I, as well as all household members have not traveled outside of the country or to any city considered to be a “hot spot” for COVID-19 infections within the past 30 days. I understand that St. Paul’s/Mornings with Mommy cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the history health provided by each participant. We kindly ask if you can not answer "YES", please do not participate in Mornings with Mommy, as to keep everyone safe and healthy.
Parent's First Name *
Parent's Last Name *
Phone Number *
Street Address
City, State and Zip Code
Number of Children Attending
Clear selection
Name of First Child *
Birth date of First Child
Name of Second Child
Birth date of Second Child
Name of Third Child
Birth date of Third Child
Do any of your children have allergies or other medical concerns we need to be aware of? *
Do you have a home church?
If this is your first time with Mornings with Mommy, how did you hear about the group?
I hereby give my consent as the parent/guardian of the above named child/children to attend/participate in the Mornings With Mommy program at Saint Paul's Lutheran Church at 6150 N. Lecanto Hwy, Beverly Hills FL 34465. My child and I hereby release, indemnify, and hold harmless the church, its employees and/or volunteers from any and all liability from any claim, injury, or loss sustained by or during my child's participation during Mornings With Mommy. I hereby authorize Saint Paul's to take and use photography and/or video of my child for crafts, keepsakes, or promotional purposes in any type of media and understand I will not be compensated for any such use. Please type your name in the box below agreeing with this consent form. *
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