Moms/Womens Connect Child Care Mom's/Women's COnnect Nursery Sign Up & Payment $30 per child for Winter/Spring *Denotes Required Field * Title Registrant Information (please complete a form for each child). * Infant Surname * Infant First Name * Gender Female Male * Date of Birth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Parent or Guardian Information * Parent or Guardian's Name: * Mailing Address (please include postal code) * Email: Home Phone: ( ) - Father's Cell Phone: ( ) - * Mother's Cell Phone: ( ) - * Church we attend: Medical Information * Care Card Number * Family Physician * Phone Number ( ) - Please list any allergies, learning/physical challenges or other information of which we should be aware for this child. * Emergency Contact (if parent or guardian is not available) * Emergency Contact Phone Number ( ) - Other adults allowed to pick up my child(ren)(please list name and relationship) Important Information The Nursery on Wednesday mornings is operated under the supervision of the Women's Ministry, NOT Little KidShine. If you have any questions or concerns please contact Dawn Hoven-Rahn dawnr@peaceportalalliance.com Age Range Nursery begins at 6 months of age. Children remain in the nursery until they are able to attend our Awana Puggles Program. Please see the Puggles registration if you have any questions. SicknessIf your child is unwell we would appreciate your consideration in keeping your at child home. In the event a child with a contagious illness was present in the Nursery,( ie. Hand, Foot & Mouth), our protocol is that we send an email out to inform everyone and then clean and sanitize all the infected areas. Refund Policy: A pro-rated refund will be given for medical-related cancellations after September 25, 2019. Outside of this reason, there will be no refunds distributed. Medical Release: I (we) give permission for my infant to participate in the Nursery program at Peace Portal Alliance Church. I understand that this activity will be closely supervised. However, should there be an emergency situation, I give my consent to all supervisors to make decisions concerning the medical treatment of my clubber. I understand that I will be notified immediately in case of emergency, and I agree not to hold Peace Portal Alliance Church liable in any way. * Medical Agreement Yes No Media Permission: I (we) give permission to the church and its directors to use photographs and video taken during Nursery for ministry promotion at Peace Portal Alliance Church, online and on our social media pages. * Media Agreement Yes No * Please enter your full name * Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 * I consent to receive email notices and the Peace Portal News. I can unsubscribe at any time. Yes No * Payment I am paying for Fall Session ($30 per child) I am paying for Fall, Winter and Spring ($60 per child) Credit card payment: click continue and complete the secure payment form. Cheque or cash payment: click continue and disregard the donation form. Please make cheque payable to Peace Portal Alliance Church and bring to the church during office hours. Please note that your registration is not complete until payment is received.
