New Life Church Atlantic - Nursery Registration

NLC Nursery Registration

Child's First Name

Child's Last Name

Birthdate

Gender

Grade

Allergies

If Your Child Has Any Special Needs that New Life Church Atlantic COGOP Nursery Workers Need To Be Made Aware Of Please Speak With the Nursery Leader.

Parent's First Name

Parent's Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Message

Emergency Contact

First Name

Last Name

Phone Number

MEDICAL TREATMENT: As a parent/guardian of this Child, I do hereby auhorize the treatment by a qualified and licensed Medical Doctor in an emergency which, in the opinion of the attending physician, may endanger the life of the student, cause a disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Yes

No

MEDIA RELEASE: As a parent or guardian of this Child, I hereby consent for New Life Church Atlantic COGOP to the use of photographs/videotape taken during the course of the year of my Child for publicity, promotional and/or educational purposes (including publications, presentation or broadcast via newspaper, internet or other media sources).

Yes

No

Date Input

Signature

Nursery registration

NLC Nursery Registration

Emergency Contact

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