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HURRY! REGISTER BY MAY 1 TO SAVE ON REGISTRATION FEES!
Current rate is $50 - fees increase to $75 after May 1

Online Registration - 2021-2022

* Indicates required field

For which session are you registering your child? *

Child's Name *

First

Last

Child's Date of Birth (MM/DD/YYYY) *

Gender *

Place of Birth (City, State or Country) *

Current Street Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Email *

Parent / Guardian 1 Name *

First

Last

Parent / Guardian 1 Phone: *

Parent / Guardian 1 Occupation *

Work Phone (if applicable) *

Parent / Guardian 1 Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Parent / Guardian 2 Name *

First

Last

Parent / Guardian 2 Phone *

Parent / Guardian 2 Occupation *

Work Phone (if applicable) *

Parent / Guardian 2 Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Is child adopted? *

Yes No

If yes (adopted), at what age was adoption? *

If yes (adopted), is child aware of adoption? *

Yes No

Please describe any custody arrangements, if applicable, regarding the child's visitation with a parent/guardian: *

Please list siblings and ages (e.g. siblings name, age): *

Please list other members living in the household (e.g. person's name, age, relationship to child): *

What are your child's favorite activities? *

Describe any fears or anxieties your child may experience: *

What behavior management practices are used for your child? *

How does your child respond to these measures of correction and discipline? *

Please list any organizations, if applicable, where your child has attended daycare or preschool: *

What learning experiences and objectives are important to you for your child's education at Kiddie Kampus? *

Please describe any concerns you may have about your child's development: *

Please describe any stressful experiences, if applicable, which may affect your child's behavior (i.e. divorce, death in the family, past abuse, etc): *

Please describe any symptoms of illness your child frequently experiences: *

Please list any allergies that affect your child: *

If your child has allergies, describe reaction symtoms: *

List any food/drink items (non-allergy related) you wish for your child to NOT have: *

Please list up to 4 individuals who may be permitted to pick up your child from school:

Individual 1 Name *

First

Last

Individual 1 Phone *

Individual 2 Name *

First

Last

Individual 2 Phone *

Individual 3 Name *

First

Last

Individual 3 Phone *

Individual 4 Name *

First

Last

Individual 4 Phone *

Please list up to 4 individuals we may contact in case of an emergency.

Emergency Contact (EC) 1 Name *

First

Last

EC 1 Phone *

EC 2 Name *

First

Last

EC 2 Phone *

EC 3 Name *

First

Last

EC 3 Phone *

EC 4 Name *

First

Last

EC 4 Phone *

Your Child's Physician / Pediatrician (Name): *

First

Last

Physician / Pediatrician Phone *

Hospital Preference *

Medical Response Agreement:
I hereby give my permission for Kiddie Kampus staff members to obtain the services of the doctor listed above (or another if your child’s primary care physician cannot be reached), EMT unit, or hospital in case the child suffers a serious illness or accident and requires medical attention.

Please indicate your agreement to the Medical Response statement above: *

Media Release Agreement:
I grant permission to Kiddie Kampus, Upland United Methodist Church (Pierce Church) and its children’s ministry, employees, and volunteers to take photographs, video, and/or electronic images of any member of my family in the children’s ministry environment. I authorize the aforementioned entities to copyright, use, and publish (i.e. Facebook) the photographs, video, and/or electronic images in print and/or electronically—with or without our names—for any lawful purpose to highlight and promote Kiddie Kampus, Upland United Methodist Church (Pierce Church) and its children’s ministry.

Please indicate your agreement to the Media Release statement above: *

Submit

Online Registration - 2021-2022

Kiddie kampus of PierceChurch.org