Mother's Day Out

Register children

My child will attend MDO	Child's Name	Name Child Goes By	Child's Age	Child's Date of Birth	Potty Trained?	Mother's Name	Father's Name	Child's Home Address	Child lives with...	Actions
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There are no Children.

Maximum number of children reached.

Do you and your family attend church regularly?*

Yes
No

If so, what church?

Name of person who will normally pick child up from MDO*

First Last

List all adults authorized to pick child up from MDO*

Emergency Numbers

Home Phone

Father Cell Phone

Father Work Phone

Mother Cell Phone

Mother Work Phone

Email

Name of person (other than parent) to contact in an emergency.

First Last

Home Phone

Cell Phone

Emergency Contact Person is a...

relative
friend of family
neighbor

Medical Information

Doctor's Name

Doctor's Phone

List any health problems

List any allergies

List any other relevant information

Supply Fee*

Price: $25.00

Registration Fee*

Total

$0.00

I have read and agree to comply with the Policy Statement for Bayside Baptist Mother’s Day Out (see back of form). It is my understanding that Bayside Baptist Church is not responsible for any injuries from accidents occurring during my child’s stay at Mother’s Day Out. I do hereby authorize emergency medical care in case of accident or medical emergency.

Name of person who filled out this form.*

First Last

Date*

This form will send you to Paypal to process the supply and registration fees. A Paypal account is not needed.