Child Care Request Form

Childcare Request Form

Parent Name: *

First

Last

Best phone number: *

Email: *

When Do You Need Childcare? *

Monday Evening Childcare
Friday Morning Childcare

Please let us know by 5:00 pm Sunday if you are requesting childcare for Monday evening Bible Study. Please let us know by 5:00 pm Wednesday if you are requesting childcare for Friday morning Bible Study.

Child Name *

Child Age (12 months to 6 years.) *

Does this Child have allergies? *

Yes - if yes, please add to the Comment section below.
No

Child 2 Name

Child 2 Age (12 months to 6 years.)

Does this Child have allergies?

Yes - if yes, please add to the Comment section below.
No

Child 3 Name

Child 3 Age (12 months to 6 years.)

Does this Child have allergies?

Yes - if yes, please add to the Comment section below.
No

Comment or Message

If you have more than 3 children to list, please include their names, ages, and if they have allergies in the Comment box. Thank you!

I have read and understand that I must submit this form by 5:00 pm Sunday to request Monday Night Childcare and by 5:00 pm Wednesday to request Friday Morning Childcare. *

Name

A community of imperfect people striving to love God and others as we reach out to the world around us with the hope God has given us through Jesus Christ.

22H West Route 313, Perkasie, Pa 18944

Mailing: PO Box 394, Dublin, Pa 18917

(215) 249-1133

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Child Care Request Form

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