Enrollment

ENROLLMENT

Please fill out the form below

Your Full Name/Spouse's full name if applicable*

Children's Names & Ages*

Email Address*

Home Address*

Parent Contacts*

Additional Emergency Names & #s*

Special Needs*

Date Selector*

Time Selector*

Please provide Reason for care needed and any further Info pertinent to your child*

Under His Wings may transport my child for events, every day travel, and emergency situations. *

May we use photos of your child in our newsletters to supporters?*

Yes

By checking this box I agree Under HIS Wings Community Center, Inc., its staff, respite care providers, board members, nor their family members, are not responsible for accidental injury, loss of limbs, accidental death, or natural disasters. I also agree that unless I notify Under HIS Wings beforehand, if I do not pick up my child or children as agreed, local authorites will be notified. *

How did you hear about us?*

Electronic Signature*

Fees/Donations

per child

Self Pay Discounted