Winter 2026 Evening Childcare Registration Form

In coordination with the St. Joesph Church MOMs group, we are offering childcare for the upcoming Fall study. Please note parents MUST stay on the church/school campus while utilizing our childcare service. If Lake Orion community schools are closed for inclement weather, childcare will be cancelled.

Child 1 Information

First Name

Last Name

Nickname

Birthdate

Gender

Male Female

Please list allergies, special needs, or other things we should know. If epipen is needed, please list where it is located (ex: Inside zipper pocket of backpack.)

Child 2 Information

First Name

Last Name

Nickname

Birthdate

Gender Male Female

Please list allergies, special needs, or other things we should know. If epipen is needed, please list where it is located (ex: Inside zipper pocket of backpack.)

Child 3 Information

First Name

Last Name

Nickname

Birthdate

Gender Male Female

Please list allergies, special needs, or other things we should know. If epipen is needed, please list where it is located (ex: Inside zipper pocket of backpack.)

Child 4 Information

First Name

Last Name

Nickname

Birthdate

Gender Male Female

Please list allergies, special needs, or other things we should know. If epipen is needed, please list where it is located (ex: Inside zipper pocket of backpack.)

Child 5 Information

First Name

Last Name

Nickname

Birthdate

Gender Male Female

Please list allergies, special needs, or other things we should know. If epipen is needed, please list where it is located (ex: Inside zipper pocket of backpack.)

If you would like to request your child(ren) to be in the same room as someone else, please list the name. We will try accommodate every request.

Primary Adult Contact - Who will be dropping off and picking up?

Name

Phone (please use dashes ex: 248-555-1212)

Address

Relationship to child

Secondary Adult Contact (In case of emergency)

First Name

Last Name

Phone (please use dashes ex: 248-555-1212)

Address

Relationship to child

Text Enrollment

Do you wish to receive text messages from us?

Yes No

By selecting "Yes" above, I am consenting to receive SMS messages from Breeze regarding information and announcements for St. Joseph Catholic Church. I understand that message and data rates may apply and message frequency varies. I can opt out by responding STOP at any time. for support I can text HELP to 87447. Please review the Breeze Privacy Policy and Terms of Service available at breezechms.com for more details.

Please also note that if you are not already enrolled and selected "Yes", you will receive an automated text from Breeze asking you to respond "YES" to complete your enrollment.

Photo/Video Release

I hereby grant St. Joseph Catholic Church permission to use photos or videos of myself and/or my child taken during the childcare program. These photos may be shared on the St. Joseph Facebook page, bulletin, or website. Last names will never be published.

Yes No

Parent Information

Click here to read Parent Information sheet. (Please read before signing form.)

I have read the Parent Information sheet.

Yes

Participation Waiver

I agree to follow program policies, as stated in this registration form. I release St. Joseph School, and any associated persons from any claims of ordinary negligence in consideration for the opportunity to particiate in this program. I hereby state that my child is in good health and able to participate in the program.

Electronic Signature

Date

Have you already submitted a picture of your license for a previous session of childcare? Yes, my license or ID is already on file.

License or ID Upload (Please upload a picture of the primary adult contact's License or ID using the button below)

Upload (8MB)

One-Time Payment for All 5 Sessions

One-time $25 registration fee for first child. $15 for each additional child.

If you're in need of financial assistance, scholarships are available. Please email Suzie Fazzini for more information: sfazz22@stjoelo.org

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Winter 2026 Evening Childcare Registration Form

Description

Please Fix the Following