Nursery

Each child requiring childcare within the nursery must have an information form on file. Please fill out this form completely and hit "submit" below. This form must be on file with the nursery staff prior to nursery services. Good for ONE year & must be renewed yearly.

Date REQUIRED Please fill out this field. Please enter a date.

Number of Children REQUIRED Please fill out this field.
Child 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 6
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 7
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 8
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 9
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.
Child 10
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate: REQUIRED Please fill out this field. Please enter a date.
- Gender: REQUIRED Male Female Please fill out this field.
- Potty-trained: REQUIRED Please fill out this field.
- Please list any food allergies or medical conditions: REQUIRED Please fill out this field.

Primary Parent Name: REQUIRED Please fill out this field. Please enter valid data.

Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Secondary Parent Name: Please enter valid data.

Cell Phone Number Please enter a phone number.

Email Please enter an email address.

PARENT PERMISSION RELEASE/AUTHORIZATION FOR MEDICAL TREATMENT:

I grant permission for my child to use all of the play equipment and participate in all of the activities at the Good Shepherd nursery. I, furthermore, release the adults in charge and Good Shepherd Catholic Church from all liability in case of accident while on the premises of the church or participating in a nursery sponsored activity. I understand that every effort will be made to contact me in the event of an emergency, however I authorize the adults in charge and any physician selected by the adults to provide emergency medical care for my child, should this be necessary. (After reading please click the box below for your consent.)

I Agree Please select this field.

IMPORTANT: Click to read the General Good Shepherd Nursery Guidelines. Please click "I agree" below to verify you have read this important document.

I Agree Please select this field.

Emergency contact person (If parents can’t be reached): REQUIRED Please fill out this field. Please enter valid data.

Emergency Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Relationship to Child: REQUIRED Please fill out this field. Please enter valid data.

Primary Parent - please type name below to verify above information is acccurate. REQUIRED Please fill out this field. Please enter valid data.

Nursery

Welcome to the Good Shepherd Catholic Church Nursery!

Child Information Form

CHildcare Requests & Questions