2023-2024 FAMILY NURSERY REGISTRATION FORM

Parents, please complete this form so we have some basic information about your child.

FAMILY INFORMATION
Parent/Guardian's First and Last Name Parent/Guardian's First and Last Name Siblings names and ages Email Home phone
#1 Child Information
Child's First and Last Name Nickname Birthdate
ALLERGIES/MEDICAL INFORMATION
Favorite Things
Please list those likes, dislikes, what comforts your child when sleepy or crying. List any other information that may be helpful to the volunteers.
#2 Child Information
Child's First and Last Name Nickname Birthdate
ALLERGIES/MEDICAL INFORMATION
Favorite Things
Please list those likes, dislikes, what comforts your child when sleepy or crying. List any other information that may be helpful to the volunteers.
#3 Child Information
Child's First and Last Name Nickname Birthdate
ALLERGIES/MEDICAL INFORMATION
Favorite Things
Please list those likes, dislikes, what comforts your child when sleepy or crying. List any other information that may be helpful to the volunteers.
#4 Child Information
Child's First and Last Name Nickname Birthdate
ALLERGIES/MEDICAL INFORMATION
Favorite Things
Please list those likes, dislikes, what comforts your child when sleepy or crying. List any other information that may be helpful to the volunteers.
BATHROOM INFORMATION
This consent is for all children listed on this form.
Do you give the adults and teens in your child's care permission to change a messy diaper?*
- YES
- NO
If potty trained, do you give us permission to help your child when they ask for help in the bathroom?*
- YES
- NO

Parent/Guardian's First and Last Name	Parent/Guardian's First and Last Name	Siblings names and ages	Email	Home phone

FAMILY INFORMATION