MDO Registration Form

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Parent/Guardian Information (school year 2017/2018)

Registration Date:____

Mother/Guardian First Name: _____________  M.I.    Last Name:____________

Address:                                                                                                                                            

Occupation:                                        Home Phone: (       )                                                            

Employed By:                                                Office Phone: (       )                                               

Cell Phone: (     )                                           Email:                                                                      

[ ] Custodial Parent (If married, mark both parents)

Marital Status:[ ] Married   [ ] Single   [ ] Divorced   [ ] Separated   [ ] Widowed

 

Father/Guardian  First Name:                              M.I.    Last Name:                                       

Address:                                                                                                                                            

Occupation:                                                    Home Phone: (       )                                                

Employed By:                                                Office Phone: (       )                                               

Cell Phone: (     )                                           Email:                                                                      

[ ] Custodial Parent (If married, mark both parents)

Marital Status:[ ] Married   [ ] Single   [ ] Divorced   [ ] Separated   [ ] Widowed   [ ]

 

Child Information

1st Child  First Name:                                 M.I.    Last Name:                                                   

Name child prefers to be called:                                            Child lives with?                               

Gender: [ ] Male   [ ] Female   Date of Birth:                                         

Age:                            Potty trained? YES    NO     

Program Attending: ___ 5 days (M-F)     ___ 3 days (M, W, & F)   ___ 2 days (T & TH)

Extended care needed?           YES    NO

Has your child ever been suspended or expelled?                    ___Yes  ___No

Has your child been retained?                                                       ___Yes  ___No

Has your child ever been diagnosed with:

Learning disability?                                                                          ___Yes  ___No

Attention Deficit Disorder?                                                             ___Yes  ___No

Central Auditory processing disorder?                                         ___Yes  ___No

Is your child currently on any medication                                    ___Yes  ___No

Is so, what medication?__________________________________________________________

Does your child have any allergies?                                               ___Yes  ___No

Please list allergies:____________________________________________________

 

2nd Child  First Name:                               M.I.    Last Name:                                                   

Name child prefers to be called:                                            Child lives with?                             

Gender: [ ] Male   [ ] Female   Date of Birth:                                         

Age: ___         Potty trained? YES    NO     

Program Attending: ____5 days (M-F)     ___ 3 days (M, W, & F)   ___ 2 days (T & TH)

Extended care needed?           YES    NO

Has your child ever been suspended or expelled?                     ___Yes  ___No

Has your child been retained?                                                       ___Yes  ___No

Has your child ever been diagnosed with:

Learning disability?                                                                          ___Yes  ___No

Attention Deficit Disorder?                                                            ___Yes  ___No

Central Auditory processing disorder?                                         ___Yes  ___No

Is your child currently on any medication                                   ___Yes  ___No

Is so, what medication?_____________________________________________________

Does your child have any allergies?                                              ___Yes  ___No

Please list allergies:_______________________________________

 

3rd Child  First Name:                                M.I.    Last Name:                                                   

Name child prefers to be called:                                            Child lives with?                               

Gender: [ ] Male   [ ] Female   Date of Birth:                                         

Age:______               Potty trained? YES    NO     

Program Attending: ___ 5 days (M-F)     ___ 3 days (M, W, & F)   ___ 2 days (T & TH)

Extended care needed?           YES    NO

Has your child ever been suspended or expelled?                     ___Yes  ___No

Has your child been retained?                                                       ___Yes  ___No

Has your child ever been diagnosed with:

Learning disability?                                                                         ___Yes  ___No

Attention Deficit Disorder?                                                            ___Yes  ___No

Central Auditory processing disorder?                                        ___Yes  ___No

Is your child currently on any medication                                   ___Yes  ___No

Is so, what medication?________________________________________________________

Does your child have any allergies?                                              ___Yes  ___No

Please list allergies:_______________________________________

 

 

Emergency Contacts & Authorized Pickup Persons:

1st Contact/Pick Up Name: _____________________________   Phone:  _____________

Relationship to the Child: __________________________

[ ] Able to pick up all children in the family

[ ] Not able to pick up the following children:________________________________________

 

2nd Contact/Pick Up Name: ___________________________   Phone:  _________________

Relationship to the Child: __________________________

[ ] Able to pick up all children in the family

[ ] Not able to pick up the following children:_________________________________________

 

3rd Contact/Pick Up Name: ___________________________   Phone:  _________________

Relationship to the Child: __________________________

[ ] Able to pick up all children in the family

[ ] Not able to pick up the following children:________________________________________

 

4th Contact/Pick Up Name: ___________________________   Phone:  _________________

Relationship to the Child: __________________________

[ ] Able to pick up all children in the family

[ ] Not able to pick up the following children:_______________________________________

 

Tuition / Payment Information:

Monthly Tuition : $                  $400 for 5 days      $240 for 3 days           $160 for 2 days

Legal guardian/ parent responsible for payment of tuition and fees.________________________

If tuition payment is the responsibility of an adult other than the parents listed above, please indicate name and contact information_______________________________________________

 

Additional Comments & Information:

Is there any other information that would be helpful to our management and teaching staff?

______________________________________________________________________________ ______________________________________________________________________________

 

Liability Release and Authorization Form

 Handbook

 I have read and agree to abide by the Grace Fellowship Mother’s Day Out Policy and Procedures Handbook.

Parent Signature: ____________________________________ Date: ______

 

Emergency Medical Attention

I ____________________ (name of parent/guardian) hereby give permission for Grace MDO to obtain emergency medical treatment, including emergency transportation for my child/children if I cannot be reached immediately. I agree to be responsible for any emergency expenses incurred.

Parent’s Signature:                                           _____                         Date:                         

Liability Release

 It is understood that Grace Fellowship PCA or any person connected with Grace Fellowship Mother’s Day Out or First Presbyterian Church Gulf Shores will not be held liable for any accident or injury to my child/children while participating in the Grace MDO Program.

Parent’s Signature:                                  _____                                  Date:                      

 

Photography Release:

I authorize Grace MDO to photograph or video my child while participating in daily activities and to use said photos or videos in photographic displays or other publications showing these daily activities while they are enrolled at Grace MDO.

Parent’s Signature:                                                                _____    Date:                      

 

 Collections of Unpaid Balances

 I understand that if my account with Grace MDO becomes delinquent to the point of collections. I agree to pay all costs of collections including attorney fees.

Parent’s Signature:                                           _____                         Date:                      

 Thank You!