Grace Kids Child Registration Form
Parent Information
Guardian 1 Name
Guardian 1 Phone Number
Guardian 1 Email Address
What is the best way to reach you?
Email
Phone Call
Text
Relation
Choose one:
Mother
Father
Grandparent
Foster Family
Other
Guardian 2 Name
Guardian 2 Phone Number
Guardian 2 Email Address
What is the best way to reach you?
Email
Phone Call
Text
Relation
Choose one:
Mother
Father
Grandparent
Foster Family
Other
Child(ren) Information
First Child's First and Last Name
First Child's Date of Birth
First Child's Grade (if in school)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
List any FOOD allergies know for first child
List any MEDICAL allergies know for first child
So that we can give your chid the best experience possible, does your first child have any physical, emotional, mental or behavioral concerns or limitations of which our staff should be aware including ADD/ADHD?
Yes, please explain below
No
Has your first child ever experienced
Seizures
Asthma
Anxiety/Panic Attacks
Separation Anxiety
Additional information you feel we should know about your first child
Second Child's First and Last Name
Second Child's Date of Birth
Second Child's Grade (if in school)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
List any FOOD allergies know for second child
List any MEDICAL allergies know for second child
So that we can give your chid the best experience possible, does your second child have any physical, emotional, mental or behavioral concerns or limitations of which our staff should be aware including ADD/ADHD?
Yes, please explain below
No
Has your second child ever experienced
Seizures
Asthma
Anxiety/Panic Attacks
Separation Anxiety
Additional information you feel we should know about your second child
Third Child's First and Last Name
Third Child's Date of Birth
Third Child's Grade (if in school)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
List any FOOD allergies know for third child
List any MEDICAL allergies know for third child
So that we can give your chid the best experience possible, does your third child have any physical, emotional, mental or behavioral concerns or limitations of which our staff should be aware including ADD/ADHD?
Yes, please explain below
No
Has your third child ever experienced
Seizures
Asthma
Anxiety/Panic Attacks
Separation Anxiety
Additional information you feel we should know about your third child
Child(ren)'s Home Address
City
State
Choose one:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Zip
Comments or additional information that might be helpful for our staff to know (Optional)
I give permission for Delaware Grace Brethren Church to use images of my child(ren) taken at Sunday morning services, Wednesday evening programs or special events for promotional materials and celebration videos.
Yes
No
SUBMIT FORM