Mother's Day Out (2018-2019)

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...
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There are no Children.

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.

Mother’s Day Out (2018-2019)