SRN PARISHIONER Nursery Registration 2022-23

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EACH FAMILY ONLY NEEDS TO FILL OUT THIS REGISTRATION FORM ONE TIME EACH YEAR.
This information is a necessity to have on file, especially in the chance of an emergency.
The sign-in process in the nursery each week is even simpler and quicker than this!
The nursery is for children ages 6 MONTHS- 3 YEARS OLD.
Nursery is available during the 9am and 11am Masses on Sundays from September-May.

Email *

Are you a registered parishioner at St. Robert of Newminster (SRN)? *

Yes, we are registered parishioners!

No, we are not parishioners yet!

We are only VISITING (STOP: please fill out the SRN VISITOR Nursery Registration form instead)!

Additional email address(es) you would like updates sent to:

Parent(s)/Guardian(s) name: *

Parent cell numbers: (example: Mary, mom: (616) 000-0000 Joseph, dad: (616) 000-0000) *

Address: *

Emergency Contact Information: please list the name, contact phone number, and relation (grandparent, friend) that we could contact in the case of emergency. This person would only be contacted if the registering parent(s) are unable to be reached.

During which Mass will you most often be using the Nursery?

9am

11am

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How often do you anticipate dropping your little one(s) off to the nursery during Mass?

Every Sunday

1-2 Sundays each month

Occasionally

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Have you used the nursery before or will this be your first year?

Yes, we have used the nursery in the past!

No, this will be our first year using it!

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Child 1 NAME: *

Child 1 DATE OF BIRTH: *please note the nursery is only for children ages 6 months through 3 years (up until their 4th birthday)* *

YYYY

Does Child 1 have any allergies? *

Yes

If Child 1 DOES have allergies, please list them here:

Does Child 1 have any medical conditions, special needs, or information that will be helpful to caregivers? If NO, please write "none." IF YES, PLEASE LIST THEM HERE: *

Child 2 Name:

Child 2 DATE OF BIRTH: *please note the nursery is only for children ages 6 months through 3 years (up until their 4th birthday)*

YYYY

Does Child 2 have any allergies?

Yes

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If Child 2 DOES have allergies, please list them here:

Does Child 2 have any medical conditions, special needs, or information that will be helpful to caregivers? If NO, please write "none." IF YES, PLEASE LIST THEM HERE:

Child 3 Name:

Child 3 DATE OF BIRTH: *please note the nursery is only for children ages 6 months through 3 years (up until their 4th birthday)*

YYYY

Does Child 2 have any allergies?

Yes

Clear selection

If Child 3 DOES have allergies, please list them here:

Does Child 3 have any medical conditions, special needs, or information that will be helpful to caregivers? If NO, please write "none." IF YES, PLEASE LIST THEM HERE:

If any of your children have not been baptized yet and you would like us to reach out with information, please let us know which child(ren) and we will be happy to reach out:

Please list the name, email address, and best phone number for anyone you may know who is interested in volunteering in the nursery. This could be you, an older sibling at least 13+, grandparent, or anyone you know who enjoys working with children!

PHOTO RELEASE: I understand that through their participation in this program, my child(ren) listed on this registration may be photographed for use in promotion of diocesan programs. *

I DO give permission for my child(ren) to be photographed during this program.

I DO NOT give permission for my child(ren) to be photographed during this program.

MEDICAL TREATMENT RELEASE: As a parent/legal guardian, I do hereby authorize first aid/medical treatment of my child in the event of an emergency, which may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. I understand that efforts will be made to reach me as soon as reasonably possible. In the event that the aforementioned required my authorization for treatment and I cannot be reached in an emergency, I hereby give my permission to the physician selected by the activity leader to hospitalize, secure medical treatment, and/or order an injection, anesthesia or surgery for the aforementioned as deemed necessary.I understand that all reasonable safety precautions will be taken at all times by the parish and its agents during faith formation programs. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold St Robert of Newminster Parish, its leaders, employees, drivers, volunteers, or the Roman Catholic Diocese of Grand Rapids liable for damages, losses, diseases, or injuries incurred by the aforementioned. This release form is completed and signed of my own free will and with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. I certify that I am the Custodial Parent/Legal Guardian of the minor child(ren) named above and agree to the terms for myself and my minor child(ren). ****BELOW IS MY TYPED NAME, SERVING AS MY SIGNATURE*** *

A copy of your responses will be emailed to the address you provided.

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