Mary&#039;s Little Helpers

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

Child's Last Name REQUIRED Please fill out this field. Please enter valid data.

Child's Gender REQUIRED Male Female Please fill out this field.

Child's Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Child's Age Range REQUIRED 8 - 24 months 2 - 4 years Please fill out this field.

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

Parent/Guardian Last Name 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.

Street 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.

Are there any allergies or medical conditions we should be aware of? REQUIRED Yes No Please fill out this field.

If yes, please explain

Does your child carry an EpiPen? (if so, please bring to sessions) REQUIRED Yes No Please fill out this field.

Is there anything else we should know?

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

Emergency Contact Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship to Child REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

I consent to photo, video, or other media portraying my child to be used in connection with his/her participation in Mary’s Little Helpers for promotional purposes at Corpus Christi Parish, including internet or print publication, although my child shall not be identified in any publication without prior approval.

I Agree Please select this field.

I understand that a parent/guardian/designated adult will be present for the entirety of each session with my child.

I Agree Please select this field.

Please choose a session. REQUIRED 40.0 – 3 Spring Sessions-Mar/Apr/May (saves $5) 15.0 – January 19 15.0 – February 16 15.0 – March 16 15.0 – April 6 15.0 – May 18 Please fill out this field.

How did you hear about Mary’s Little Helpers? Corpus Christi Parishioner Gingham Giraffe Carnival Word of Mouth Social Media Other

If other, please enter Please enter valid data.