Friday, July 30, 2010 You Are Here: basics / preschool and children / mother's day out / mdo application for admission  | 

Mother's Day Out Application for Admission
mdo application
Days you would like your child to attend:

*Child's name:
*Child's date of birth:
Child's gender:
*Home address:
*Home Phone:
Mother's Contact information
Mother's Name:
Employer:
Occupation:
Phone numbers:
Father's Conact Information
Employer:
Occupation:
Phone numbers:
Number of Siblings:
Names and Ages:
Other people living in household:
Church affiliation:
Does your child attend regularly?:
Has your child attended other preschool programs?:
How did you find out about our program? :
****Emergency/Medical Information*****
Health Insurance Company:
Phone Number:
Policy Holder:
Child's Physician:
Hospital Preference (If required, but not life threatening):
Does your child have any allergies?:
If yes, what are they and how severe:
What is the usual treatment for reactions?:
Does your child have any other medical conditions that we should be aware of?:
If yes, please list:
Name of emergency contacts if we are unable to reach parents:
Who is able to pick up your child (other than yourself)?:
Is there anyone who might attempt to pick up your child against your wishes? :

Copyright 2009 "Holladay Baptist Church"
 
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