Please list your child(rens) information: First Name: _____________________________________________ Last Name: _____________________________________________ Date of Birth: ____________________________________________ Will attend childcare in Kids Corner:
Yes
No
First Name: _____________________________________________ Last Name: _____________________________________________ ☐ Registration fee of $50 paid in full ☐ Pay by semester ($25 due now, $25 due January 1)
Date of Birth: ____________________________________________ Will attend childcare in Kids Corner:
Yes
No
Registration Information (Please print clearly)
First Name: _____________________________________________
First Name: ________________________________________
Last Name: _____________________________________________
Last Name: ________________________________________
Date of Birth: ____________________________________________
Contact Number:____________________________________
Will attend childcare in Kids Corner:
Yes
No
Street Address: _____________________________________ First Name: _____________________________________________ City, Zip: __________________________________________ Last Name: _____________________________________________ Email Address: _____________________________________ Date of Birth: ____________________________________________ Birthdate: _________________________________________ Will attend childcare in Kids Corner: Do you attend LifePoint Church?
Yes
Yes
No
No
If not, where do you attend (if applicable): __________ __________________________________________________ Emergency contact’s name and phone number: ___________ __________________________________________________
Please return your check (made payable to LifePoint Church) and registration form to Amanda’s mailbox at LifePoint or mail it to Amanda Sheets 2244 Treva Way, Greenwood IN 46143. Registration can also be completed at www.lifepointindy.com Questions about… -the MUMs program, contact Amanda Sheets (
[email protected] or 317-414-4826) or Allison Crispin (
[email protected] or 317-518-7994)
