Date Night Childcare
CHILD INFORMATION
Name
Birthdate
Gender
-
Boy
Girl
Grade
-
Pre-school
K
1
2
3
4
5
ADDITIONAL CHILD INFORMATION
Name
Birthdate
Gender
-
Boy
Girl
Grade
-
Pre-school
K
1
2
3
4
5
Replace this with a title or description
Name
Birthdate
Gender
-
Boy
Girl
Grade
-
Pre-school
K
1
2
3
Replace this with a title or description
Name
Birthdate
Gender
-
Boy
Girl
Grade
-
Pre-school
K
1
2
3
4
5
HEALTH INFORMATION
Family Physician
Physician's Phone
Health Insurance Company
Policy Number
Are there any health or allergy concerns or anything we should be aware of so that your child(ren) may have a successful experience?
LIABILITY INFORMATION
Release of Liability
I agree that Crown of Glory Lutheran Church and the Connect guides are not responsible for accidental injuries that occur during my child(ren)'s time at church. I authorize such medical treatment as is necessary and such additional procedures as are considered necessary on the basis of finding during the course of medical examination.
By submitting this form acknowledge that I have read and fully understood the above statements.
Select
Yes
No
Media Waver
I understand my child(ren) and I may be photographed during Crown of Glory activities and events, and these images may be included in Crown of Glory publications and social media sites. No child's name will be included with their photo without parental consent.
Select
Yes
No
PARENT/GUARDIAN INFORMATION
Parent Name
Parent Name
Church Membership
Yes - Church Member
No - Non-Member
No - Interested in Membership
Primary Mailing Address
Best Phone Number
Best Email
VOLUNTEER OPPORTUNITIES
We need shepherds!
Please check this box if you are, or someone in you household (6th grade or older), would like to be a group leader.
DONATION INFORMATION
Which form of payment would you like to use?
The registration fee is $5 per child. Please contact Krysta Flaharty for scholarship information. You may either use cash, check, or PayPal. If you use PayPal, you will be taken to a page where you can enter in all your information.
Cash or check (Mail to Crown of Glory, 1141 Cardinal St., Chaska, MN 55318)
PayPal (You will be re-directed to PayPal)
Submit