New Life
Presbyterian
Church

Childcare Registration

Parent / Guardian
Parent's Name
Parent's Phone*
Email
Address*
Street Address City State / Province / Region ZIP / Postal Code
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Pediatrician
Pediatrician Name
Pediatrician Phone
Children
Children*
Name Date of Birth Allergies or Medical Conditions
Please share any information that would help New Life Care for your Children
Consent*
I give permission for the above-named children to participate in the programs for children at New Life Presbyterian Church. I also authorize the above names individuals to sign my child(ren) into and out of childcare programs at New Life Presbyterian Church.