First Fridays Registration Form

Your name *

Email address *

Guardian/Caregiver's Name

Phone number *

Address *

Do you want to add another parent/guardian's contact information? *

Yes

Parent/Guardian's Name

Phone number

Address

Special Needs Disgnosis *

If siblings are attending, please list their name, current age, and birthday

Please list activities your child likes to engage in (i.e., music, stories, coloring, physical games, independent play, group activities, reading, being read to, etc.) *

My child needs encouragement to: *

My child does not enjoy: *

Please do not ask my child to: *

My child learns/participates best when the adult: *

Vision *

Normal

Impaired

Blind

Other

Hearing *

Normal

Impaired

Deaf

Hearing Aid

Other

Motor *

Head Control

Rolls Over

Sits

Crawls

Cruises

Walks

Other

Assistance *

Walker

Crutches

Braces

Wheelchair

Other

Toileting Skills *

Toilets Independently

Potty trained - needs help

Currently being potty trained

Diapers

Other

Please specify what help may be needed: *

Word or sign that child uses for toileting needs: *

Eating Habits *

No restrictions

Soft foods only

Can take nothing by mouth

Bottle only

Other

Sleeping Habits *

Likely to sleep before 9 pm

If sleeping: crib or pallet?

Enjoys rocking

Change to sleep wear

Other

COMMUNICATION WITH OTHERS

Communicates with others using *

Words

Phrases

Sentences

Babbles

Gestures

Sign Language

Other

Can understand what others say *

All of the time

Most of the time

Some of the time

Other

Behavior *

Outgoing

Shy

Adapts to new situations well

Adapts to a new situation with difficulty

Responds to correction well

Responds to correction with difficulty

Is sometimes destructive

Sometimes threatens others

Sometimes hits/bites or hurts self/others

Sometimes attempts to run away

Hyperactive and/or ADD

Plays in groups

Other

My child responds to separation from his/her parents by *

My child is best comforted by: *

My child lets someone know what he/she wants or needs by: *

We have a pet(s), named:

Siblings

Name, age, birthday

Favorite toy/stuffed animal *

Will be with child? *

Yes

Fears or dislikes (i.e., dogs, loud sounds, certain food/activity): *

Other information about your child that would help while in our care: *

Would you like to add another participant? *

Yes

Liability Release and Medical Authorization

Parent/Guardian Name(s) *

In addition to the Paren/tGuardian, my child may be picked up by: (please list name and relationship)

Liability Release Statement

I/We hereby assume all risk in connection with care for our child at First Fridays. I/We further agree to hold harmless and indemnify, voluntarily release and forever discharge First United Methodist Church - Arlington, its staff, associates, volunteers, and/or agents for any illness, injury, or financial obligation that may occur as a result of this instruction. My express intention is that such release and indemnity will apply to any claim, suit, damages, or liability whatsoever arising in whole or in part of my negligence, the negligence of First United Methodist - Arlington or any of its employees, officers, agents, volunteers, or servants, or any other person's negligence, whether the negligence is sole negligence, comparative negligence, concurrent negligence, joint negligence, gross negligence, or any form of negligence.

Medical Care Authorization

I/We authorize First United Methodist - Arlington, its employees or agents to render or obtain such emergency medical care or treatment as may be necessary should any injury, harm or accident occur to my child while participating at First Fridays.

Digital Signature *

Full Name

Guardian/Caregiver's Name

Address

Parent/Guardian's Name

Participant 1

Activities

PHYSICAL NEEDS

COMMUNICATION WITH OTHERS

Other Information

Liability Release and Medical Authorization

Liability Release Statement

Medical Care Authorization