Sensory Room Enrollment Form
The information contained on this enrollment form will be for Sensory Room use only. A copy will be kept by the Peace UCC superintendent and the relevant classroom supervisor.
Sign in to Google to save your progress. Learn more
Child's Name *
Birthdate
MM
/
DD
/
YYYY
School/Grade
Street Address
City
State *
Zip *
Best Contact Phone Number *
Email *
Parent/Guardian Name *
Emergency Phone (in case parents/guardians cannot be reached) *
Names of other persons authorized to receive the child (if applicable) *
Please be aware that my child is allergic to:
Does your child have any medical condition we should be aware of?
In case of medical emergency, what steps should be taken? *
Our family physician is
Phone number of physician
Waiver Disclaimer: I hereby authorize my child to participate in the Sensory Room Program at Peace UCC and hereby release and waiver any claim, demand, cause of action or assertion of liability against Peace UCC, its pastors, staff, or volunteers, which may result from any accident or happening occurring during or as a result of such activity. Please type your name (Parent/Guardian) and date as a digital signature of understanding. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms