Parent/ Guardian 1:

E-Mail:

This E-Mail is :Home    Work

Home Phone:    Preferred

Work Phone:    Preferred

Cell Phone:    Preferred

May we list your cell phone in our directory?    Yes    No

Street/Apt:

City/State/Zip:

If address is same for both parents, leave second blank.

Parent/Guardian 2:

E-Mail:

This E-Mail is :Home    Work

Home Phone:    Preferred

Work Phone:    Preferred

Cell Phone:    Preferred

May we list your cell phone in our directory?    Yes    No

Street/Apt:

City/State/Zip:

Childs Name:

Birth Date:

Food/Medical Allergies or Restrictions:

Photo Release: By checking this, I give Heritage Church permission to use un-named photos of my child on their website and/or publications. Thank you for helping us show others our vibrant church community!

Emergency Information:

Emergency contact:

Emergency contact Number:

Are there any person(s) restricted from contact with your child?    Yes    No

If Yes, please specify:

Survey Questions:

Which service(s) does your family usually attend?

    9:30 am (Sunday School)

    10:30 am (Sunday Morning Worship)

    6:00pm (Sunday Evening Worship)

    6:30 pm (Wednesday Family Night)

Is your child potty trained:    Yes    No

Is your child allowed on the playground?    Yes    No

Is your child allowed to have snacks?    Yes    No

May we publish your contact information in the Student Ministries Directory?    Yes    No

Thank you for your time!

Your Nursery Directors are David and Crystal Walters