NHBC Kids Registration

Please fill out this form and click submit.

Email

*

This address will receive a confirmation email

Student Name

*

Student Preferred Name

*

Student Birthdate

*

Address

*

Last Grade Completed

*

Please select all that apply.

My child is 2-3 years old My child is 4-5 years old and has not attended Kindergarten Kindergarten 1st 2nd 3rd 4th 5th

Parent/Guardian Name

*

Parent /Guardian Phone

*

Can we text you about your child?

*

Please select all that apply.

Yes No

Emergency Contact (Name not listed above)

*

Emergency Contact Phone #

*

Emergency Contact Relationship to Student

*

Please check if your child is allergic to any of the following. Check all that apply

*

Please select all that apply.

Bee Stings Poison Ivy Poison Sumac

If any items were checked, please describe their reaction

*

Please list any Food Allergies and your child's reaction

*

Please list any Medication Allergies and your child's reaction

*

Has your child been diagnosed with any of the following?

*

Please select all that apply.

Asthma Diabetes Epilepsy Autism

Does your child have any other special needs that we need to be aware of?

*

Does your child need transportation provided by the church? Please note that transportation is not always available.

*

Please select all that apply.

Yes No Sometimes

Insurance Carrier

*

Description

Please fill out this form and click submit.

Please Fix the Following

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