Child Intake Form

You only need to fill this form out once per year, per child. Thank you!

We need to get a little information about you and your child. All information will be accessible by our staff for safety and communication purposes.

Please fill out one form per child. A link to this form will be sent with the confirmation email for additional children.

Parent/Guardian Name

This address will receive a confirmation email

Phone

Address

Relationship

If other, please explain.

Parent/Guardian #2

Phone

Address (if different from above)

Relationship

If other, please explain

Child's Information

Child's Name (first, last)

Nickname/Preferred Name

Birthdate

Potty Trained? (for nursery age children)

Is there any other information about your child that you would like to share with us?

Medical Information

Children are typically given goldfish crackers, fruit snacks and juice for snacks unless otherwise directed.

Does your child have any medical, environmental, or food allergies?

Please list any allergies and treatment

Medical & Liability Release

During activities at or sponsored by St. Martin-in-the-Fields Episcopal Church, in the event of sickness or medical emergency, I request that my child receive any medical attention or treatment deemed necessary. I give permission to any hospital, doctor, or health care provider to transport, treat, admit, and/or care for my child. In the event that I am not present at the time of the emergency or cannot be contacted, I entrust my child's care to the staff and/or designated ministry leadership of St. Martin-in-the-Fields Episcopal Church.

Emergency Contact

Name

Phone

Child Intake Form

Description

Please Fix the Following