St. Mark Children’s Day Out

Fall 2017 Registration Form

Child

First ______Middle ______Last ______Gender: Male __ Female__

Birth date _____/_____/______Age (on September 1, 2017) _____ Street Address ______

City ______State ______Zip code ______Child’s Home Phone ______

Parent/Guardian - Contact Information

Parent/Guardian #1

First______Last______Ms. Mrs. Mr. Other ______

Work Phone ______Cell phone ______E-MAIL______

Occupation ______Employer ______

Parent/Guardian #2

First______Last______Ms. Mrs. Mr. Other ______

Cell phone ______E-mail______

Occupation ______Employer ______

Child lives with: ______

Please list any medical problems, including any required maintenance medication (i.e. Diabetic, Asthma, Seizures).

Medical Problem Required treatment Should paramedic be called?

______Yes/No

______Yes/No

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

Yes__ No__ If yes, explain:______

Is your child allergic to any type of food or medication?

Yes__ No__ If yes, explain:______

Does your child require a special diet?

Yes__ No__ If yes, explain:______

Please circle the day/days that you wish for your child to attend

MONDAY TUESDAY WEDNESDAY THURSDAY

Please indicate how you heard about St. Mark Children’s Day Out

Website ______YELP ______Church ______Word of Mouth ______Other; please share______

Church Affiliation:______

Terms of Agreement

I understand that by paying the $100 Registration fee that I am intending to enroll my child ______for the 2017-2018 school year that begins on Tuesday, September 5, 2017 and ends on Thursday, May 17, 2018. I agree to pay my child’s tuition by the 5th of each month, understanding that I also agree to pay September 2017 and May 2018 tuition due by

September 5, 2017. If my child needs to leave St. Mark CDO before May 17, 2018, I will give the director at least 30 days written notice in order to utilize my May tuition as my final month’s payment. I also understand that this $100 registration is non-refundable. St. Mark Children’s Day Out guarantees my child enrollment on the days circled above.

Parent Signature______Date______

OFFICE USE ONLY:

DATE RECEIVED______Check#______Staff initials______