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______