Nursery Registration

- Parish Life
Contact Us
- Marci Rittmanic
  
  Nursery Coordinator
  
  260-432-0268
  mrittmanicseasfw.org

Thank you for your interest in using our Nursery. A Registration Form is required for all children using the Nursery. Please complete this form and submit it or you can complete a paper version of this form available in the Parish Nursery. (Note - please read our Nursery Policy prior to completing the Registration Form.)

If you have any questions, please feel free contact our Parish Nursery Coordinator, Marci Rittmanic.

Nursery Registration Form

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Family Last Name REQUIRED Please fill out this field. Please enter valid data.
Is Family registered at St. Elizabeth Ann Seton Catholic Church? REQUIRED Yes No Please fill out this field.
Child 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
Child 2
- First Name Please enter valid data.
  
  Last Name Please enter valid data.
- Age Please enter valid data.
Child 3
- First Name Please enter valid data.
  
  Last Name Please enter valid data.
- Age Please enter valid data.
Child 4
- First Name Please enter valid data.
  
  Last Name Please enter valid data.
- Age Please enter valid data.
Additional Children
- Please include the names and ages of any additional children in the section below.
- Names and Ages
Parent/Guardian Information
- Parent 1 Name REQUIRED Please fill out this field. Please enter valid data.
- Parent 1 Primary Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Parent 1 Alternate Phone Number Please enter a phone number.
- Parent 1 Email REQUIRED Please fill out this field. Please enter an email address.
- Parent 2 Name Please enter valid data.
- Parent 2 Primary Phone Number Please enter a phone number.
- Parent 2 Alternate Phone Number Please enter a phone number.
- Parent 2 Email REQUIRED Please fill out this field. Please enter an email address.
- Home Address (Street 1) REQUIRED Please fill out this field. Please enter valid data.
- Street 2 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.
Emergency Contact Information
- Please note: this should not be the child's parent or guardian.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Primary Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Alternate Phone Number Please enter a phone number.
Allergies and Medical Information
- Please advice of any allergies or medical issues that we need to be aware of during your child's time in the nursery.
- Comments

Signature

By typing my name below and submitting this form, I acknowledge that I have received a copy of the Nursery Policy for Saint Elizabeth Ann Seton and agree to its terms. I also certify that I am the Parent/Guardian of child(ren) listed on this registration.

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

Last Name REQUIRED Please fill out this field. Please enter valid data.
I Agree Please select this field.

Submit