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Fellowship Friends Waiting List Registration Form
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First Name
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Last Name
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Email Address
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Phone Number
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Address Line 1
Address Line 2
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City
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State/Province/Region
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Zip/Postal Code
Please note:
Completion of this form does not guarantee a spot in our program. You will be notified when a spot becomes available for your child.
Are you interested in joining our School Year or Summer program?:
-- Select --
School Year
Summer
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Child's Full Name:
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Name Child Goes By:
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Child's Date of Birth:
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Child's Age:
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Child's Gender:
-- Select --
Male
Female
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Child's Home Address - Including City, State, and Zip Code:
Home Phone (if applicable):
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Father's Name:
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Father's Place of Employment:
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Father's Cell/Work Phone:
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Mother's Name:
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Mother's Place of Employment:
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Mother's Cell/Work Phone:
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Most Frequently Checked Email Address:
Names of Child's Siblings (if applicable):
Parent's Church Home:
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List two emergency contacts (name and phone number), other than parents::
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Medical Clinic:
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Child's Doctor's Name:
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Are child's immunizations up to date?:
Yes
No
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Does child have any know allergies? If yes, please list below::
Yes
No
Allergies::
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Does child have any physical limitations/problems? If yes, please list below::
Yes
No
Physical Limitations/Problems::
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Other persons who may pick up your child from Fellowship Friends are::
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Throughout the year, we will take pictures of your child individually and in groups while participating in preschool activities. These photographs will be used for class activities and crafts and may be displayed in the classroom or in brochures or other marketing material for Fellowship Friends. Your child will not be identified by name in any marketing materials.
I give permission for my child to be photographed and placed on the Fellowship Friends Facebook page or in other marketing material.
Yes
No
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I understand I have to give a 2 week written notice before dropping and agree to pay all fees due. I hereby release this Parents Day Out and Fellowship Bible Church from liability and I authorize emergency medical care for my child if I am unable to be contacted.
Yes
No
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Parent's Initials (Electronic Signature):
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Date of Electronic Signature:
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