Wednesday Night Childcare
Please fill out this form and click submit.
Adult Name
*
Name & age of your child. If you are dropping off multiple children you can list all of them here.
*
Email
*
This address will receive a confirmation email
Cell Phone (this number will receive text notification if necessary)
*
Secondary Cell Phone #
Whose number is this?
*
Does your child/children have any allergies?
*
Please select all that apply.
Yes
No
Option
If yes, please explain.
Are there any other things you would like us to know about your child/children?
If there are any other adults or siblings (of driving age) that you authorize to pick up your child, please list those names here:
Submit
Description
Please fill out this form and click submit.
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