Crossroads Baptist Church

Parent/Guardian Name *

First Name

Last Name

Phone *

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Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child Needing Childcare *

First Name

Last Name

Child Needing Childcare

First Name

Last Name

Child Needing Childcare

First Name

Last Name

Due to Limited Capacity in our facility, please identity your need for Childcare: *

Urgent - Parents/Guardians are working outside of the home and help is needed.

Moderate - We can make other arrangements, but it is increasingly difficult.

Low - It would be nice to have Childcare.

I Affirm the following: *

I affirm that I, as well as all household members, do not currently have or are experiencing symptoms of Covid-19 .

I understand the risk involved in placing my child at Crossroads Baptist Daycare and I release Crossroads Baptist Daycare from any and all liability for the unintended exposure or harm that could potentially derive from Covid-19.

Name *

First Name

Last Name

Name *

First Name

Last Name