Mary&#039;s Little Helpers

Child's First Name REQUIRED Please fill out this field. Please enter valid data.

Child's Last Name REQUIRED Please fill out this field. Please enter valid data.

Child's Gender REQUIRED Male Female Please fill out this field.

Child's Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Child's Age Range REQUIRED 8 - 24 months 2 - 4 years Please fill out this field.

Parent/Guardian First Name REQUIRED Please fill out this field. Please enter valid data.

Parent/Guardian Last Name REQUIRED Please fill out this field. Please enter valid data.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Street Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Are there any allergies or medical conditions we should be aware of? REQUIRED Yes No Please fill out this field.

If yes, please explain

Does your child carry an EpiPen? (if so, please bring to sessions) REQUIRED Yes No Please fill out this field.

Is there anything else we should know?

Emergency Contact First Name REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship to Child REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Do we have permission to use photos/videos of your child on Parish publications, media, and website? REQUIRED Yes No Please fill out this field.

I understand that a parent/guardian/designated adult will be present for the entirety of each session with my child. REQUIRED Yes Please fill out this field.

How did you hear about Mary’s Little Helpers? Corpus Christi Parishioner Gingham Giraffe Carnival Word of Mouth Social Media Other

If other, please enter Please enter valid data.