Child's Name *

First Name

Last Name

Nickname

First Name

Last Name

Date of Birth *

MM

DD

YYYY

1st Parent or Guardian's Name *

A parent / guardian is expected to be on church property when their child is being cared for in the church nursery.

First Name

Last Name

Cellular Phone *

We ask that you bring your cell phone to church so we may text if you are needed.

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please select the snacks that your child may eat

Cheerios

Animal Crackers

Raisins

Alternate Snack?

I'd prefer to bring an alternate snack.

If needed, I would like the nursery staff to change my child’s diaper *

If you answered (No) we will notify you with a text so you may come and change the diaper.

Yes

No

After using the potty, I would like the nursery staff to assist with wiping *

For the safety of both children and nursery staff; diapers will always be changed in the presence of two nursery workers. If a child needs assistance in the bathroom, the door will be left open while being helped

Yes

No

Soothing Time *

If within the time you select all efforts have been exhausted we will notify you immediately. • Our staff and volunteers are not permitted to administer any medications. Please make sure that there are no medications in your child’s diaper bag.

2 Minutes

5 Minutes

10 Minutes

More than 10 minutes

I give my permission for WLCC to use my child’s photograph on bulletin boards, website and WLCC publications.

Yes

No

Virtual Signature *

Please enter your full name as a signature proxy. Your signature confirms your approval of any content submitted on this form.

First Name

Last Name