Mother’s Day Out Registration Form

Please indicate the days of the week you would like to schedule your child’s attendance:

____ Monday 8:30 am – 12:30 pm

____ Wednesday 8:30 am – 12:30 pm

____ Friday 8:30 am – 12:30 pm E-MAIL ADDRESS:________________________

Any Schedule changes made after 30 days of attendance will be subject to a processing fee.

General Information

Name of Child: _________________________ Name Used at Home: _________________________

Birthdate: __/__/__ Present Age: ______ Sex: ___M ___F Phone Number: __________________

Address: _____________________________________________________________________________

Parents are: Married ____ Separated ____ Divorced ____ Adoptive Parent ____ Grandparent ____

Full name of Mother: _________________________________________ Cell Phone: _________________

Address: _________________________________________________ Home Phone: _________________

Place of work: _____________________ Address: _____________________ Work Phone: _____________

Full name of Father: _________________________________________ Cell Phone: __________________

Address: _________________________________________________ Home Phone: __________________

Place of work: _____________________ Address: _____________________ Work Phone: _____________

Church you attend: ______________________ If nonmember, give church preference_______________

Childs Doctor ______________________________ Phone_____________________________________

In case of emergency I authorize the following person(s) to act in my behalf:

1. Name: ________________________________ 2. Name: ___________________________________

Relationship to child: ____________________ Relationship to child: _______________________