Peninsular Florida District

District Council 2008

Child Care Pre-Registration Form

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Child care will be provided during the evening services

for children up to 5 years of age.

Children will only be released to parent/guardian

registered on this form.

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What is your email address?

Have questions or need more information?

How many children to be registered in child care? Select One123More than 3

(one online registration per family please)

Parent/Guardian First and Last name

1.  
2.  

Phone Number During Evening Services  

Child #1

Child #1 First and Last Name

Child #1: Age Select One12345 

Requesting Child Care During These Services:

(please select all that apply)                                Monday 7 pm    

                                                                   Tuesday 7 pm           

                                                                   Wednesday 7 pm

Special Instructions:

Child #2

Child #2 First and Last Name

Child #2 Age Select One12345

Requesting Child Care During These Services:

(Please select all that apply)                                        Monday 7 pm

                                                                   Tuesday 7 pm

                                                                   Wednesday 7 pm

Special Instructions:

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Child #3

Child #3 First and Last Name

Child #3 Age Select One12345

Requesting Child Care During These Services:

(Please select all that apply)                                   Monday 7 pm

                                                                    Tuesday 7 pm

                                                                    Wednesday 7 pm

Special Instructions:

WAIVER AGREEMENT

I understand and agree that by typing my name in this box

and submitting this form, I release and hold harmless the Peninsular Florida District Council of the Assemblies of God and the International Plaza Resort and Spa, its trustees, officers, employees, and volunteers from any liability, past or future, fully and completely. I authorize the executive staff or designated medical professionals to administer emergency medical assistance if I cannot be reached.