Nursery/Childcare Registration Form 2023-2024

Please complete this form if your family is planning to use our childcare for worship, adult education, or other reasons. We need a new form for each family every program year (July-June). If you have more than 2 children to register for the nursery, please contact Becky at children@hslckirkland.org to help with additional registrations.

If you have any questions, please contact Becky at children@hslckirkland.org.

Adult 1 Name

First Name

Last Name

Adult 1 Cell Phone

(###)

###

####

Adult 2 Name

First Name

Last Name

Adult 2 Cell Phone

(###)

###

####

Family Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Family Email Address

Member?

Yes

Adults Authorized to Pick Up Children

Child 1 Name

First Name

Last Name

Child 1 Preferred Name

Child 1 Gender

Child 1 Birthdate

YYYY

Child 1 Baptism Date

YYYY

Child 1 Any Known Allergies (food, environment, etc.)

Child 1 Special Needs/Challenges Your Child Faces

Information is kept confidential.

Child 2 Name

First Name

Last Name

Child 2 Preferred Name

Child 2 Gender

Child 2 Birthdate

YYYY

Child 2 Baptism Date

YYYY

Child 2 Any Known Allergies (food environment, etc.)

Child 2 Special Needs/ Challenges Your Child Faces

Information is kept confidential

I give my permission to Holy Spirit Lutheran church to use photographs and videos of my child/ren in public displays, media releases and social media. I understand these photographs will not be sold or used for commercial purposes.

If I cannot be reached, I give permission for nursery staff to call for medical assistance while my child is in nursery care.

Please write your name below.