Enrollment Form

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1 Please print clearly in blue or black ink. Enrollment Form Child s Full Name: Birth Date: Address: Home Phone: ( ) City: State: Zip Code: Nickname: Pick-up Password: Enrollment options: Wednesday only Friday only Both Days Mother s Name: Driver s License Number: Home Phone: ( ) Cell Phone: ( ) Address: (if different) City: State: Zip Code: Employer Name: Work Phone:( ) Father s Name: Driver s License Number: Home Phone: ( ) Cell Phone: ( ) Address: (if different) City: State: Zip Code: Employer Name: Work Phone:( ) Marital Status: Married Divorced Separated Widowed Single Living Together If Divorced, who has custody of the child? Is non-custodial parent allowed to pick up child? Yes No Other children/individuals living in the home: (attach separate paper if needed) Name Age: Relationship Name Age: Relationship Name Age: Relationship

2 Persons authorized to pick up your child, or authorized to be contacted in the event MDO Preschool cannot reach you, or in case of emergency. Name: Driver s License # Phone ( ) Name: Driver s License # Phone ( ) Name: Driver s License # Phone ( ) NOTE: If the person is not listed here, he/she will not be allowed to pick up your child Emergency Contacts Primary Emergency Contact (Other than parent/guardian): Relationship to Child: Home Phone: ( ) Other Phone: ( ) Address: Secondary Emergency Contact (Other than parent/guardian): Relationship to Child: Home Phone: ( ) Other Phone: ( ) Address: AUTHORIZATION FOR THE FOLLOWING: PHOTOS: MDO Preschool will at times take still photos of children participating in different activities. These photos are for MDO Preschool use. On occasion, the newspaper will have news articles and ask to publish children s pictures. I/we give our permission for my/our child to be photographed. I give permission to publish pictures on the Westwood Baptist Church publications, Westwood Baptist Church social media pages, Westwood Baptist Church web sites. Yes No Parent Signature Parent Signature TRANSPORTATION: I/We hereby give my/our consent to Westwood Baptist Church Mother s Day Out Preschoool to provide for any transportation for my/our child in an emergency evacuation away from the church conducted and supervised by MDO Preschool's staff. I/We understand that in the event of an emergency I/we will be notified of the point of relocation as soon as possible. FIELD TRIPS: I/We hereby give my/our consent for Westwood Baptist Church MDO Preschool to supervise transportation for field trips away from the church conducted and supervised by the MDO Preschool s staff. I/We understand that 48 hours before a field trip MDO Preschool will post a notice stating the group of children that will be on the trip and where and when they will depart and return. DISCIPLINE: The only form of discipline MDO Preschool will administer is "Time Out" (a brief period of isolation from his/her group). By my/ our signature, I/we are giving our consent for my/our child to be placed in "Time Out". Parent Signature Parent Signature

3 Medical Information Child s Physician: Phone ( ) Physician Address: City Zip Insurance Company Policy # Regular Medication Medication Allergies Food Allergies Other Allergies Any Special Health Conditions Is Child Current on all immunization? Yes No Please provide a copy of immunization record for Westwood Baptist Church Mother s Day Out Preschool. Emergency Release Consent for Emergency First Aid and Transportation: I hereby give permission that my child,, may be given emergency treatment by a staff member at Westwood Baptist Church Mother s Day Out Preschool. I also give permission for my child to be transported by car or ambulance to an emergency center for treatment, and agree to hold Westwood Baptist Church and it s employees harmless. Parent/Guardian Signature Date: Consent for Medical Care and Treatment: In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician, and hold Westwood Baptist Church and it s employees harmless. Parent/Guardian Signature Date: Sworn to and subscribed before me this day of, 20. Notary Public

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5 Physician HEALTH STATEMENT: Child s name: Date of Birth has been examined within the past twelve (12) months and is physically able to participate in the activities of the child care and/or Mother s Day Out Preschool program. Medications: Allergies: Special Needs: Immunizations: Is child current on immunizations? Yes or NO Please attach a copy of current immunization records. Clinic /Physician s Printed Name Date Examined Clinic /Physician s Address Clinic /Physician s Phone No. Physician's Signature

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7 Initial all sections PARENT/GUARDIAN ENROLLMENT AGREEMENT I/We understand that MDO Preschool closes at 2:45 P.M. and that I/we will pay a late fee of $1.00 per minute, per child after 2:45 P. M. The clock on the desk determines the time. I/We agree to pay tuition on time for Mother s Day Out Preschool in advance on the first attending day of each month. Tuition will be paid monthly at the current rate of $75/month for 1 day a week and $130/month for 2 days a week. This is a monthly rate regardless of the number of days in attendance that month. I/We agree and understand that tuition is considered late after the 10th of each month. A late fee of $25 per week will be due unless prior notification and arrangements have been made with the director. I/We understand that if I/we am/are two weeks past due in payments, that my/our child may be dropped from the Program unless other arrangements have been made with the Director. I/We have received and read the current Parent Handbook and agree to abide by the regulations and requirements stated there in. Westwood Baptist Church MDO Preschool Program and the parents/guardians understand and agree that: 1. This agreement is a contract binding for both MDO Preschool and the parent/guardian. 2. This contract may be terminated by either the parent/guardian or MDO Preschool upon notification of intention at least two weeks in advance, or at any mutual agreement of both parties. Parent/Guardian Signature Parent/Guardian Signature MDO Preschool Director Signature For office use only: Westwood Baptist Church MDO Preschool hereby grants approval of enrollment to: Parent/Guardians on behalf of their child beginning (first full day attending) and throughout the remainder of the school year. Monthly tuition rate is $. This rate is valid for the school year only. Any changes in tuition are subject to Director approval. Special notes or arrangements: MDO Preschool Director Signature Date

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