Hello! We're glad that you are interested in the Mornings with Mommy program. We would like you to fill out the registration form to get to know you and your child(ren), and to be prepared for any special needs. You can register for one or more play dates.
If you have any questions or prefer to register by phone, please contact Nicole Westra at: firstname.lastname@example.org or (585) 397-4130. Thank you!
(Required fields are marked with red asterisks.)
Parent- First Name*
Parent- Last Name*
Home Address: Street *
Home Address: City, State*
Which play dates are you registering for? (Select one or more)*
5. March 14th - Fun with Food
6. April 11th - Butterflies & Easter - Jesus is Risen!
7. May 9th - Sparkles, Muffins & Mother's Day
8. June 13th - S'mores, Camping & Father's Day
Number of children attending*
First Child's Name (full)*
First Child's Age (y=years; m=months)*
First Child's Birthday*
If you are registering one child only, skip to the LAST QUESTIONS section.
Second Child's Name (full)
Second Child's Age (y=years; m=months)
Second Child's Birthday
Third Child's Name (full)
Third Child's Age (y=years; m=months)
Third Child's Birthday
Do any of the children have allergies or other medical concerns we need to be aware of? (Please describe if Yes).
Do you have a home church? (Y / N)*
I hereby give my consent as the parent/guardian of the above named child/children to attend/participate in the Mornings With Mommy program at Prince of Peace Lutheran Church (6020 Pittsford-Palmyra Rd., Fairport, NY). My child and I hereby release, indemnify, and hold harmless the church, its employees and/or volunteers from any and all liability from any claim, injury, or loss sustained by or during my child's participation during Mornings With Mommy. (Checkbox below)*
Photo release: I hereby authorize Prince of Peace Lutheran Church to take and use photography and/or video of my child for crafts, keepsakes, or promotional purposes in any type of media and understand I will not be compensated for any such use. Please type your name in the box below agreeing with this consent form. (Checkbox below)
Confirmation: If you entered an email address above we will email you a confirmation of this registration. Otherwise we will send a confirmation in the US mail.