REGISTRATION FORM Register Your Child Child's Name* First Last Child's Birthdate MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail* Who is authorized to pick up your child? (Must be at least 18 years old)If needed, would you like for our nursery workers to change your child's diaper?* Yes No We provide juice and crackers during the program. Is that okay?* Yes No Any allergies, special needs, or extra information? Name of Person Filling Out the Form* First Last I hereby give consent for Grace Church to use on their website or in print media all photographs in which I/my child appear(s) while involved in the ministries of Grace Church.* Yes No Questions or Comments
