Care Ministries Childcare Registration |

Name - adult attending DivorceCare or Single & Parenting and who is also registering the child(ren) for the free child care*
First Last
Parent's Email

Please enter the e-mail address, if you have one, of the parent attending DivorceCare or Single & Parenting. We will use this as a main form of communication with you. We promise your e-mail address will not be sold or shared with anybody. If you do not have e-mail then we will communicate directly with you via your phone number.
Number of Children to Register*
Please enter a number from 1 to 3.
Child's Name*
First Last
Birth Date*
Date Format: MM slash DD slash YYYY
2nd Child's Name*
First Last
Birth Date*
Date Format: MM slash DD slash YYYY
3rd Child's Name*
First Last
Birth Date*
Date Format: MM slash DD slash YYYY
Home Address - if different than parent registering for DivorceCare or Single & Parenting
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Home Phone Number*
Please enter the home phone number where the child primarily lives.
Name of person child(ren) live with*
Who has custody?*
If Other, please specify the name of the person who has custody of the child(ren)?*
Are there any special accomodations we need to be aware of regarding your child(ren)?*
Specify the special accomodations*
Does the Child(ren) have any allergies, especially to food?*
Specify the allergy(ies) and which Child(ren) they apply to*
Is there anything else our child care providers should know about your child(ren)?*
Please specify what else we should know*
Emergency Contact Name*
First Last

Enter the name of the person to be contacted in the case of an emergency.
Emergency Contact Phone Number*
Enter the phone number for the person you've listed as your emergency contact.
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