Knox Church -2019 – 2020 Children’s Ministry Registration

Parent's Information

Parent 1 First Name *

Parent 1 Last Name *

Parent 1 Email *

Parent 1 Cell Phone *

This is the phone we will use on Sunday AM to contact you in case of emergency.

Parent 2 First Name

Parent 2 Last Name

Parent 2 Email

Parent 2 Cell Phone

We will use this as a secondary emergency contact number on Sunday mornings.

Street Address *

Apt. or Building number

City *

Zip Code *

Family Phone *

Information about Child

Child First Name *

Child Last Name *

Child's Date of Birth *

What class are you registering this child for during the 2019-2020 school year? *

Note: We ask that children be registered for the class that matches the class they are, or will be, in in school.

Does this child have any allergies, e.g. to medication, environmental factors or food (including food intolerances)? *

Yes

No

If so, please describe:

Does this child have any additional medical conditions? *

Yes

No

If so, please describe:

Is this child receiving any support services for developmental or learning concerns (such as an IEP or 504 Plan)?

Yes

No

If yes, have you already filled out a Special Blessings Intake Form?

Yes

No

Would you be willing to? Doing so would give us information that will assist us in caring for your child, even if you do not desire specific involvement from the Special Blessings Ministry.

Yes

No, thank you

Thank you.

Please complete the Special Blessings Intake Form.

Is there anything else we should know about this child, and the learning environment in which s/he best thrives?

e.g. Sensory sensitivities or physical limitations

Yes

No

If so, please describe:

Would you like to be contacted about our Special Blessings ministry for children needing additional support in order to participate successfully in our programs?

Yes, Please

No, Thank You

Snacks are given to the children during most programs. We provide pretzels, animal crackers and Goldfish crackers for elementary age children. Early childhood groups are served Cheerios, Life cereal and Goldfish crackers. These are all nut free.

PLEASE NOTE: We CANNOT guarantee that these have been produced in facilities that do not also produce food containing nuts.

May we give this child these snacks? *

Yes

No

If this child is not able to eat the snacks we typically provide, will you be providing your own snack? (Note: Please notify room staff that you are providing a substitute snack.)

Yes

No

Would you like to register another child? *

Yes

No

Information about Child 2

Child First Name

Child Last Name

Child's Date of Birth

What class are you registering this child for during the 2019-2020 school year?

Note: We ask that children be registered for the class that matches the class they are, or will be, in in school.

Does this child have any allergies, e.g. to medication, environmental factors or food (including food intolerances)?

Yes

No

If so, please describe:

Does this child have any additional medical conditions?

Yes

No

If so, please describe:

Is this child receiving any support services for developmental or learning concerns (such as an IEP or 504 Plan)?

Yes

No

If yes, have you already filled out a Special Blessings Intake Form?

Yes

No

Would you be willing to? Doing so would give us information that will assist us in caring for your child, even if you do not desire specific involvement from the Special Blessings Ministry.

Yes

No, thank you

Thank you.

Please complete the Special Blessings Intake Form.

Is there anything else we should know about this child, and the learning environment in which s/he best thrives?

e.g. Sensory sensitivities or physical limitations

Yes

No

If so, please describe:

Would you like to be contacted about our Special Blessings ministry for children needing additional support in order to participate successfully in our programs?

Yes, Please

No, Thank You

Snacks are given to the children during most programs. We provide pretzels, animal crackers and Goldfish crackers for elementary age children. Early childhood groups are served Cheerios, Life cereal and Goldfish crackers. These are all nut free.

PLEASE NOTE: We CANNOT guarantee that these have been produced in facilities that do not also produce food containing nuts.

May we give this child these snacks?

Yes

No

If this child is not able to eat the snacks we typically provide, will you be providing your own snack? (Note: Please notify room staff that you are providing a substitute snack.)

Yes

No

Would you like to register another child?

Yes

No

Information for Child 3

Child First Name

Child Last Name

Child's Date of Birth

What class are you registering this child for during the 2019-2020 school year?

Note: We ask that children be registered for the class that matches the class they are, or will be, in in school.

Does this child have any allergies, e.g. to medication, environmental factors or food (including food intolerances)?

Yes

No

If so, please describe:

Does this child have any additional medical conditions?

Yes

No

If so, please describe:

Is this child receiving any support services for developmental or learning concerns (such as an IEP or 504 Plan)?

Yes

No

If yes, have you already filled out a Special Blessings Intake Form?

Yes

No

Would you be willing to? Doing so would give us information that will assist us in caring for your child, even if you do not desire specific involvement from the Special Blessings Ministry.

Yes

No, thank you

Thank you.

Please complete the Special Blessings Intake Form.

Is there anything else we should know about this child, and the learning environment in which s/he best thrives?

e.g. Sensory sensitivities or physical limitations

Yes

No

If so, please describe:

Would you like to be contacted about our Special Blessings ministry for children needing additional support in order to participate successfully in our programs?

Yes, Please

No, Thank You

Snacks are given to the children during most programs. We provide pretzels, animal crackers and Goldfish crackers for elementary age children. Early childhood groups are served Cheerios, Life cereal and Goldfish crackers. These are all nut free.

PLEASE NOTE: We CANNOT guarantee that these have been produced in facilities that do not also produce food containing nuts.

May we give this child these snacks?

Yes

No

If this child is not able to eat the snacks we typically provide, will you be providing your own snack? (Note: Please notify room staff that you are providing a substitute snack.)

Yes

No

Would you like to register another child?

Yes

No

Information for Child 4

Child First Name

Child Last Name

Child's Date of Birth

What class are you registering this child for during the 2019-2020 school year?

Note: We ask that children be registered for the class that matches the class they are, or will be, in in school.

Does this child have any allergies, e.g. to medication, environmental factors or food (including food intolerances)?

Yes

No

If so, please describe:

Does this child have any additional medical conditions?

Yes

No

If so, please describe:

Is this child receiving any support services for developmental or learning concerns (such as an IEP or 504 Plan)?

Yes

No

If yes, have you already filled out a Special Blessings Intake Form?

Yes

No

Would you be willing to? Doing so would give us information that will assist us in caring for your child, even if you do not desire specific involvement from the Special Blessings Ministry.

Yes

No, thank you

Thank you.

Please complete the Special Blessings Intake Form.

Is there anything else we should know about this child, and the learning environment in which s/he best thrives?

e.g. Sensory sensitivities or physical limitations

Yes

No

If so, please describe:

Would you like to be contacted about our Special Blessings ministry for children needing additional support in order to participate successfully in our programs?

Yes, Please

No, Thank You

Snacks are given to the children during most programs. We provide pretzels, animal crackers and Goldfish crackers for elementary age children. Early childhood groups are served Cheerios, Life cereal and Goldfish crackers. These are all nut free.

PLEASE NOTE: We CANNOT guarantee that these have been produced in facilities that do not also produce food containing nuts.

May we give this child these snacks?

Yes

No

If this child is not able to eat the snacks we typically provide, will you be providing your own snack? (Note: Please notify room staff that you are providing a substitute snack.)

Yes

No

Do you have additional children to register?

If so, we ask that you please finish the questions below and submit a new form.

Authorizations

Grades Prekindergarten - 2nd grade: You may authorize up to two people to pick up your child (or children).

NOTE: Nursery, Toddler 1, Toddler 2 and Toddler 3 rooms use a pager and sign-in system for child drop-off & pick-up. The person picking up your child must have the pager.

Would you like to authorize additional people?

Yes

No, only I (and my spouse, if applicable) can pick up my child or children

Not applicable, (my child(ren) is/are not in this age group)

Name

Relationship to Child (or Children)

Cell Phone Number

Would you like to authorize a second additional person to pick up your child (or children)?

Yes

No

Name

Relationship to Child (or Children)

Cell Phone Number

Still photographs and videotapes may be taken of programs and events. Do you give permission for Knox Church to use your child(ren)'s picture(s) in the event that their image appears in a video or still picture?

(choose one)

Yes, for internal use only (no online photos or videos)

Yes, for internal and online use

No

I authorize the church staff and/or volunteers to act on my behalf to approve appropriate emergency, medical treatment in the event I cannot be reached.

Yes

No

Mid-Week Programs

In addition to Sunday morning programs, I would like to register for or receive information about Kindergarten through 6th grade Wednesday evening programs.

Yes

No

Additional Comments

Thank you! Our Mid-week Program Director, Kristen Meehan, will contact you.

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