Nursery Registration Form

Child's Information:

Number of Children in The Basilica of Saint Andrew Nursery REQUIRED Please fill out this field.
Child 1
- Child's full name REQUIRED Please fill out this field. Please enter valid data.
- Child's date of birth REQUIRED Please fill out this field. Please enter valid data.
- Male/Female REQUIRED Male Female Please fill out this field.
- Allergies and/or important medical information: REQUIRED Please fill out this field. Please enter valid data.
- Favorite Activities: REQUIRED Please fill out this field. Please enter valid data.
- Does not like / is upset by: REQUIRED Please fill out this field. Please enter valid data.
Child 2
- Child's full name REQUIRED Please fill out this field. Please enter valid data.
- Child's date of birth REQUIRED Please fill out this field. Please enter valid data.
- Male/Female REQUIRED Male Female Please fill out this field.
- Allergies and/or important medical information: REQUIRED Please fill out this field. Please enter valid data.
- Favorite Activities: REQUIRED Please fill out this field. Please enter valid data.
- Does not like / is upset by: REQUIRED Please fill out this field. Please enter valid data.
Child 3
- Child's full name REQUIRED Please fill out this field. Please enter valid data.
- Child's date of birth REQUIRED Please fill out this field. Please enter valid data.
- Male/Female REQUIRED Male Female Please fill out this field.
- Allergies and/or important medical information: REQUIRED Please fill out this field. Please enter valid data.
- Favorite Activities: REQUIRED Please fill out this field. Please enter valid data.
- Does not like / is upset by: REQUIRED Please fill out this field. Please enter valid data.
Child 4
- Child's full name REQUIRED Please fill out this field. Please enter valid data.
- Child's date of birth REQUIRED Please fill out this field. Please enter valid data.
- Male/Female REQUIRED Male Female Please fill out this field.
- Allergies and/or important medical information: REQUIRED Please fill out this field. Please enter valid data.
- Favorite Activities: REQUIRED Please fill out this field. Please enter valid data.
- Does not like / is upset by: REQUIRED Please fill out this field. Please enter valid data.

Home 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.

Parent / Guardian Information:

Parent / Guardian Name(s) 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.

Additional Information:

Name(s) of persons authorized to pick up your child: REQUIRED Please fill out this field. Please enter valid data.

Names of parents / guardians volunteering in Nursery: REQUIRED Please fill out this field. Please enter valid data.

Has individual named above attended a VIRTUS "Protecting God's Children" training? REQUIRED Yes No Please fill out this field.

To register for a VIRTUS training, please click HERE.

After you click "SUBMIT", you should receive a confirmation email. If you do not receive an email, please contact Kathy Boyer at [email protected].