Bethlehem Baptist Church of Springfield - Mother's Day Out Application + Registration FORM 2

Parent First Name

Parent Last Name

Email

Child's Name:

Child's Date of Birth:

Child's Age:

Street Address:

City | State |

Zipcode:

Home Phone #:

Mom's Phone #:

Mom's Work Phone #:

Dad's Phone #:

Dad's Work Phone #:

Overall Best Cell Phone # to contact:

Emergency Contact #1 (Name, Relationship to Child, Phone #)

Emerency Contact #2 (Name, Relationship to Child, Phone #):

Emergency Contact #3 (Name, Relationship to Child, Phone #):

Please list anyone who has permission to pick up your child:

Allergies:

Is your child potty trained?
Yes
No

How does your child react in a social enviroment?

Is your child bringing any medications to school?
Yes
No

If yes, please list and state dosage:

I understand that:
Medication MUST be in its original prescription bottle or package, with the child's name, dosage and administration instructions clearly indicated.

In case of a medical emergency, I understand that hospital policy requires parental permission before treatment. I hereby give my permission to a representative of Bethlehem Baptist Church Mother’s Day Out program to administer medication as identified above and to secure proper medical treatment.

Best Phone # to contact in case of emergency:

Child's Pediatrician:

Child's Pediatrician Phone #:

Child's Dentist:

Child's Dentist Phone #:

Are you and your family attending church regularly? If so, where?

2022 Policies

I agree to and understand the following:
My child must arrive no later than 9:00am each Tuesday and Thursday

If my child is later than 9:30am, they will not be admitted

Child pick-up time is 2:00pm

If I am later than 2:00pm to pick up my child, there will be a $5 fee for every 5 minutes past 2:00pm

There is a $30/yr registration fee

Tuition is $18/day and is due before the 1st of every month

Tuition is due regardless of if my child is present or absent on any given day. If my child is to be withdrawn from classes, a 2-week notice is required.

Liabilities for acts of my child while he/she are under the care of our facility are my (the parents’) responsibility. Excessive discipline problems will be reported to the parents, if unresolved, MDO reserves the right to ask that the child be removed from the program.

POLICY ON SICKNESS: Do not bring a child with the following symptoms: fever within the past 24 hours, diarrhea, vomiting, pink eye, headache, unexplained rash or bumps, runny nose ,(green or yellow) skin infections, sore throat or a persistent cough. Please notify the director if your child has a contagious disease such as chicken pox, strep, head lice or intestinal parasites. For a serious illness a doctor’s note will be required for the child to return.

All Children will need the following:

I will provide the following for my child:
A complete set of extra clothes (placed in a Ziploc bag with the child’s name on it). Please have children wear appropriate shoes for playing on the playground/gym time.

A blanket and mat for nap/rest time (except for the nursery)

Diapers/pullups and wipes for my child. (Your teacher will let you know when your child is running low.)

Checkboxes
Snack, Lunch and drink (NO GLASS CONTAINERS OR CARBONATED BEVERAGES. Please do not pack anything that needs to be heated or that your child can not feed themselves. You may send an extra drink for snack time.)

Media Release Form

Children love to see photos of themselves as well as their friends. We sometimes use these photos to record our projects, as parts of games and for other use around the classroom. Please indicate if you give permission for your child’s photo to be taken for classroom use.
Yes
No

We are on Facebook. On our Mother’s Day Out Facebook page we share news and reminders. We also share information about your child’s program and activities during the year. Please indicate if you give your permission to include your child’s photo on this site.
Yes
No

Please type your name below ("I have read, understand, and agree to the all the above"):

Today's Date:

Mother's Day Out Application + Registration Form

2022 Policies

All Children will need the following:

Media Release Form

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