Mother's Morning Out Registration

Sixes UMC Mother's Morning Out Registration Form

There is a one-time per annum enrollment fee of $20.00. Enrollment Fee is non-refundable and is

in addition to the daily tuition rate. Registration does not guarantee space on any particular day.

Daily tuition will be due at the beginning of each session.

Child's Last Name: Date:

Child's First Name: Nickname:

Birthdate:

Parent/Guardian #1 (primary contact person) Parent/Guardian #2

Name: Name:

Cell Phone: Cell Phone:

Home Phone: Home Phone:

Work Phone: Work Phone:

Email: Email:

Address:

Does the child live with both parents? Yes No

Is there any special custody information? Yes No

If so, please provide:

Does the child have any allergies? Yes No

If so, please list:

Does the child have special needs? Yes No

If so, please list:

List medications the child receives on a regular basis:

Please list any people (full names as they appear on the drivers license) allowed to pick up the child from Sixes United Mother's Morning Out Program and their relationship to the child:

Emergency Contact Name: Emergency Phone Number:

Days registering for: Tuesday Thursday Tuesday and Thursday